Provider Demographics
NPI:1083762207
Name:KLAGGE, CONNIE J (PT)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:J
Last Name:KLAGGE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10805 39TH DR SE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-5428
Mailing Address - Country:US
Mailing Address - Phone:425-357-1809
Mailing Address - Fax:425-357-8519
Practice Address - Street 1:1809 100TH PL SE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-3829
Practice Address - Country:US
Practice Address - Phone:425-357-1809
Practice Address - Fax:425-357-8519
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00005242173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB20378Medicare ID - Type Unspecified