Provider Demographics
NPI:1770664963
Name:KIMBALL, STEPHANIE R (LMP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:R
Last Name:KIMBALL
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 1:1614 OAKES AVE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-2052
Mailing Address - Country:US
Mailing Address - Phone:425-259-6707
Mailing Address - Fax:
Practice Address - Street 1:6501 196TH ST SW STE C
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-5980
Practice Address - Country:US
Practice Address - Phone:425-775-2288
Practice Address - Fax:425-778-5476
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00015401225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist