Provider Demographics
NPI:1689724874
Name:KITTILSON, ANDREA LYN (LMP)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:LYN
Last Name:KITTILSON
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 1:34024 1ST PL S
Mailing Address - Street 2:APT. # B
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6566
Mailing Address - Country:US
Mailing Address - Phone:253-334-6053
Mailing Address - Fax:
Practice Address - Street 1:721 M ST. S.E.
Practice Address - Street 2:SUITE #105
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002
Practice Address - Country:US
Practice Address - Phone:253-939-9599
Practice Address - Fax:253-804-5655
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00015434225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0194690OtherL & I