Provider Demographics
NPI:1568722130
Name:WILSON, KAREN M (LMP)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:M
Last Name:WILSON
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 1:11802 NE 65TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-5521
Mailing Address - Country:US
Mailing Address - Phone:360-253-6883
Mailing Address - Fax:360-892-7040
Practice Address - Street 1:11802 NE 65TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-5521
Practice Address - Country:US
Practice Address - Phone:360-253-6883
Practice Address - Fax:360-892-7040
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-17
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00005476225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist