Provider Demographics
NPI:1881016012
Name:KAUFFMAN, CARLY JEAN (LMT)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:JEAN
Last Name:KAUFFMAN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3516 N GOVERNMENT WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-8303
Mailing Address - Country:US
Mailing Address - Phone:208-966-4397
Mailing Address - Fax:
Practice Address - Street 1:3516 N GOVERNMENT WAY
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-8303
Practice Address - Country:US
Practice Address - Phone:208-966-4397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-07
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMASG-390225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist