Provider Demographics
NPI:1083137988
Name:MCCONKIE, KATHRYN MARIE
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MARIE
Last Name:MCCONKIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 764
Mailing Address - Street 2:
Mailing Address - City:CARLTON
Mailing Address - State:OR
Mailing Address - Zip Code:97111-0764
Mailing Address - Country:US
Mailing Address - Phone:503-857-7935
Mailing Address - Fax:
Practice Address - Street 1:21370 SW LANGER FARMS PKWY STE 138
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:OR
Practice Address - Zip Code:97140-9140
Practice Address - Country:US
Practice Address - Phone:503-625-6247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-23
Last Update Date:2017-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR023387172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist