Provider Demographics
NPI:1407345994
Name:SMART, KIRA (LMP)
Entity Type:Individual
Prefix:
First Name:KIRA
Middle Name:
Last Name:SMART
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 1:4510 INTELCO LOOP SE STE A
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-6005
Mailing Address - Country:US
Mailing Address - Phone:360-402-6776
Mailing Address - Fax:
Practice Address - Street 1:4510 INTELCO LOOP SE STE A
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-6005
Practice Address - Country:US
Practice Address - Phone:360-402-6776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60826739225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist