Provider Demographics
NPI:1306008024
Name:SANFORD, KELLY A (LMP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:SANFORD
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 1:1107 S 347TH PL
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6718
Mailing Address - Country:US
Mailing Address - Phone:253-838-3777
Mailing Address - Fax:253-874-6874
Practice Address - Street 1:1107 S 347TH PL
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6718
Practice Address - Country:US
Practice Address - Phone:253-838-3777
Practice Address - Fax:253-874-6874
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00014382225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist