Provider Demographics
NPI:1063468585
Name:KIKILLUS, PAMELA J (PT, DSC)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:J
Last Name:KIKILLUS
Suffix:
Gender:F
Credentials:PT, DSC
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:J
Other - Last Name:LEERAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DSC
Mailing Address - Street 1:9315 GRAVELLY LAKE DR SW
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-1574
Mailing Address - Country:US
Mailing Address - Phone:253-581-5200
Mailing Address - Fax:253-581-5203
Practice Address - Street 1:8011 112TH STREET CT E
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-7814
Practice Address - Country:US
Practice Address - Phone:253-848-0662
Practice Address - Fax:253-848-8567
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00005876225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA444955OtherLABOR & INDUSTRIES
WA8346983Medicaid
WA9605LEOtherREGENCE BLUESHIELD
WA8930578OtherL&I CRIME VICTIMS PROG
WA8346983Medicaid