Provider Demographics
NPI:1225245350
Name:KIM, TERISA Y (LMP)
Entity Type:Individual
Prefix:
First Name:TERISA
Middle Name:Y
Last Name:KIM
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 1:6205 200TH STREET S.W
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036
Mailing Address - Country:US
Mailing Address - Phone:425-775-5052
Mailing Address - Fax:425-775-1838
Practice Address - Street 1:6205 200TH ST SW
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-6053
Practice Address - Country:US
Practice Address - Phone:425-775-5052
Practice Address - Fax:425-775-1838
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00015156174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist