Provider Demographics
NPI:1588018659
Name:SAMPSON, KELLY (PT, MOMT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SAMPSON
Suffix:
Gender:F
Credentials:PT, MOMT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:LUNDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, MOMT
Mailing Address - Street 1:3636 WOODSIDE CT
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98226-4195
Mailing Address - Country:US
Mailing Address - Phone:206-818-4149
Mailing Address - Fax:
Practice Address - Street 1:3636 WOODSIDE CT
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-4195
Practice Address - Country:US
Practice Address - Phone:206-818-4149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-14
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT 00003769225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0127353OtherL&I