Provider Demographics
NPI:1164672812
Name:TYSLAND, KELLY (LMP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:TYSLAND
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4720- 200TH STREET SOUTHWEST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036
Mailing Address - Country:US
Mailing Address - Phone:425-776-0803
Mailing Address - Fax:425-776-0813
Practice Address - Street 1:4720 200TH ST SW
Practice Address - Street 2:SUITE 100
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-6645
Practice Address - Country:US
Practice Address - Phone:425-776-0803
Practice Address - Fax:425-776-0813
Is Sole Proprietor?:No
Enumeration Date:2008-09-30
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60040829225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist