Provider Demographics
NPI:1083761423
Name:BUCHANAN, KELLY MARK (LMT)
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:MARK
Last Name:BUCHANAN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 S 336TH ST STE 110
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6389
Mailing Address - Country:US
Mailing Address - Phone:253-312-2217
Mailing Address - Fax:
Practice Address - Street 1:500 S 336TH ST
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6389
Practice Address - Country:US
Practice Address - Phone:253-312-2217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00015776174400000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty