Provider Demographics
NPI:1447746425
Name:MARTIN, KELLY KEEN (LMP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:KEEN
Last Name:MARTIN
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 1:11803 NE 124TH AVE UNIT D39
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-2094
Mailing Address - Country:US
Mailing Address - Phone:360-433-2629
Mailing Address - Fax:
Practice Address - Street 1:15814 NE 182ND AVE
Practice Address - Street 2:
Practice Address - City:BRUSH PRAIRIE
Practice Address - State:WA
Practice Address - Zip Code:98606-9701
Practice Address - Country:US
Practice Address - Phone:360-433-2629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-02
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA.60852914225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist