Provider Demographics
NPI:1598072209
Name:PEMBERTON, KARA RAE (LMP/PTA)
Entity Type:Individual
Prefix:MISS
First Name:KARA
Middle Name:RAE
Last Name:PEMBERTON
Suffix:
Gender:F
Credentials:LMP/PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 COLUMBIA PARK TRL
Mailing Address - Street 2:SUITE 102
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-4711
Mailing Address - Country:US
Mailing Address - Phone:509-396-3707
Mailing Address - Fax:509-396-3710
Practice Address - Street 1:1455 COLUMBIA PARK TRL
Practice Address - Street 2:SUITE 102
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-4711
Practice Address - Country:US
Practice Address - Phone:509-396-3707
Practice Address - Fax:509-396-3710
Is Sole Proprietor?:No
Enumeration Date:2010-09-02
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60078473225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist