Provider Demographics
NPI:1083115950
Name:COREY, KAYLEE GRACE (LMT)
Entity Type:Individual
Prefix:
First Name:KAYLEE
Middle Name:GRACE
Last Name:COREY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 W MYSTERY AVE STE B
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-6335
Mailing Address - Country:US
Mailing Address - Phone:907-521-8002
Mailing Address - Fax:509-834-7696
Practice Address - Street 1:1212 W MYSTERY AVE STE B
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654
Practice Address - Country:US
Practice Address - Phone:907-521-8002
Practice Address - Fax:509-834-7696
Is Sole Proprietor?:No
Enumeration Date:2018-02-26
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK128350225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist