Provider Demographics
NPI:1467115865
Name:KINLAW, GEORGIE L
Entity Type:Individual
Prefix:
First Name:GEORGIE
Middle Name:L
Last Name:KINLAW
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 1:8360 CITY CENTRE DR STE 110
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-3381
Mailing Address - Country:US
Mailing Address - Phone:612-450-5906
Mailing Address - Fax:
Practice Address - Street 1:8360 CITY CENTRE DR STE 110
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-3381
Practice Address - Country:US
Practice Address - Phone:612-450-5906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-21
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN34-01-MTL225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist