Provider Demographics
NPI:1912039280
Name:TALLEY, KATHY LYNNE (LMP)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:LYNNE
Last Name:TALLEY
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:PO BOX 25249
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98093-2249
Mailing Address - Country:US
Mailing Address - Phone:206-399-6370
Mailing Address - Fax:253-942-3918
Practice Address - Street 1:204 S 348TH ST
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-7041
Practice Address - Country:US
Practice Address - Phone:206-399-6370
Practice Address - Fax:253-942-3918
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00013670174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA00013670OtherWA ST. MASSAGE LICENSE