Provider Demographics
NPI:1508209420
Name:KILBOURNE, TERRI LYNN (MA 00004895)
Entity Type:Individual
Prefix:MS
First Name:TERRI
Middle Name:LYNN
Last Name:KILBOURNE
Suffix:
Gender:F
Credentials:MA 00004895
Other - Prefix:MS
Other - First Name:TERRI
Other - Middle Name:LYNN
Other - Last Name:KILBOURNE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA 00004895
Mailing Address - Street 1:62408 FOREST GLEN WAY E
Mailing Address - Street 2:
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022-8088
Mailing Address - Country:US
Mailing Address - Phone:360-663-0260
Mailing Address - Fax:
Practice Address - Street 1:1710 RAILROAD STREET
Practice Address - Street 2:ENUMCLAW DAY SPA
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022
Practice Address - Country:US
Practice Address - Phone:360-825-5755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-10
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00004895174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist