Provider Demographics
NPI:1689092074
Name:WAYLAND LLEWELLIN, KIM (LAC)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:WAYLAND LLEWELLIN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:GREEN
Other - Middle Name:
Other - Last Name:LLEWELLIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5412 N WILLIAMS AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-2740
Mailing Address - Country:US
Mailing Address - Phone:971-373-8378
Mailing Address - Fax:
Practice Address - Street 1:5412 N WILLIAMS AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-2740
Practice Address - Country:US
Practice Address - Phone:971-373-8378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-02
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC150271171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist