Provider Demographics
NPI:1891075917
Name:MCMANIMON, KIERAN JOSEPH (LMP)
Entity Type:Individual
Prefix:
First Name:KIERAN
Middle Name:JOSEPH
Last Name:MCMANIMON
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18724 35TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST PARK
Mailing Address - State:WA
Mailing Address - Zip Code:98155-2602
Mailing Address - Country:US
Mailing Address - Phone:206-364-1481
Mailing Address - Fax:844-291-7711
Practice Address - Street 1:18724 35TH AVE NE
Practice Address - Street 2:
Practice Address - City:LAKE FOREST PARK
Practice Address - State:WA
Practice Address - Zip Code:98155
Practice Address - Country:US
Practice Address - Phone:206-364-1481
Practice Address - Fax:844-291-7711
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-20
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60228942225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist