Provider Demographics
NPI:1366826927
Name:LEVERETT, KYSHANDRA LEE
Entity Type:Individual
Prefix:
First Name:KYSHANDRA
Middle Name:LEE
Last Name:LEVERETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1609 PERKINS AVE
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99354-2807
Mailing Address - Country:US
Mailing Address - Phone:509-627-9222
Mailing Address - Fax:
Practice Address - Street 1:1609 PERKINS AVE
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99354-2807
Practice Address - Country:US
Practice Address - Phone:509-627-9222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-14
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60579299225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist