Provider Demographics
NPI:1760810402
Name:TURNER, IVY KATHLEEN
Entity Type:Individual
Prefix:
First Name:IVY
Middle Name:KATHLEEN
Last Name:TURNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:IVY
Other - Middle Name:KATHLEEN
Other - Last Name:BRAACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:3811 NE 3RD CT
Mailing Address - Street 2:APT G111
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98056-4145
Mailing Address - Country:US
Mailing Address - Phone:918-261-6902
Mailing Address - Fax:
Practice Address - Street 1:670 NW GILMAN BLVD
Practice Address - Street 2:SUITE B2
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-2444
Practice Address - Country:US
Practice Address - Phone:425-427-6562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60387401225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist