Provider Demographics
NPI:1316381957
Name:RANDALL, KYLA BRIANNE (LMP)
Entity Type:Individual
Prefix:
First Name:KYLA
Middle Name:BRIANNE
Last Name:RANDALL
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 1:235 NE DOGWOOD ST
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-2919
Mailing Address - Country:US
Mailing Address - Phone:425-623-5939
Mailing Address - Fax:
Practice Address - Street 1:7605 SE 27TH ST
Practice Address - Street 2:SUITE 103
Practice Address - City:MERCER ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98040-2835
Practice Address - Country:US
Practice Address - Phone:206-275-4870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-25
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA.60317077225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist