Provider Demographics
NPI:1922284199
Name:KRUGER, MANDY LYNN (LMT)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:LYNN
Last Name:KRUGER
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 1:4004 NE MALLORY AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-1065
Mailing Address - Country:US
Mailing Address - Phone:971-227-7567
Mailing Address - Fax:
Practice Address - Street 1:125 NE KILLINGSWORTH ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-2625
Practice Address - Country:US
Practice Address - Phone:971-227-7567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-17
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12673225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist