Provider Demographics
NPI:1437355153
Name:COYKENDALL, LAURA SAMPLE (PT)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:SAMPLE
Last Name:COYKENDALL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:GERTRUDE
Other - Last Name:SAMPLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:2012 NW KIMBALL RD
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-9571
Mailing Address - Country:US
Mailing Address - Phone:360-697-1279
Mailing Address - Fax:
Practice Address - Street 1:19319 7TH AVE NE STE 108
Practice Address - Street 2:
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-7442
Practice Address - Country:US
Practice Address - Phone:360-779-3777
Practice Address - Fax:360-779-3797
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00003870225100000X
WAPT00038702251E1300X, 2251G0304X, 2251H1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251E1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistElectrophysiology, Clinical
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4111589Medicaid
911940669OtherTAX ID
911940669OtherTAX ID