Provider Demographics
NPI:1528389285
Name:WATSON, KRISTINE DIANE (LMP)
Entity Type:Individual
Prefix:MISS
First Name:KRISTINE
Middle Name:DIANE
Last Name:WATSON
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:PO BOX 987
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:WA
Mailing Address - Zip Code:98610-0987
Mailing Address - Country:US
Mailing Address - Phone:503-860-1341
Mailing Address - Fax:
Practice Address - Street 1:461 WIND RIVER RD
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:WA
Practice Address - Zip Code:98610
Practice Address - Country:US
Practice Address - Phone:503-860-1341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-17
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020988225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist