Provider Demographics
NPI:1508147786
Name:CLARK, KATRINA ANN (LMP)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:ANN
Last Name:CLARK
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 1:505 W HIGHWAY 2
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LEAVENWORTH
Mailing Address - State:WA
Mailing Address - Zip Code:98826-9007
Mailing Address - Country:US
Mailing Address - Phone:509-548-8081
Mailing Address - Fax:
Practice Address - Street 1:505 W HIGHWAY 2
Practice Address - Street 2:SUITE 100
Practice Address - City:LEAVENWORTH
Practice Address - State:WA
Practice Address - Zip Code:98826-9007
Practice Address - Country:US
Practice Address - Phone:509-548-8081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-01
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60235994225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist