Provider Demographics
NPI:1578346904
Name:BENNETTE, KELLY LEIGH (LMT)
Entity Type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:LEIGH
Last Name:BENNETTE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10102 LAUREL CREST LN SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98498-4442
Mailing Address - Country:US
Mailing Address - Phone:253-389-8805
Mailing Address - Fax:
Practice Address - Street 1:1011 E MAIN STE 201
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-6779
Practice Address - Country:US
Practice Address - Phone:253-845-2013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA18589225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist