Provider Demographics
NPI:1922376508
Name:MORTENSEN ELDRED, KIPPI G (LMP)
Entity Type:Individual
Prefix:
First Name:KIPPI
Middle Name:G
Last Name:MORTENSEN ELDRED
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 1:101 E MAIN ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-1519
Mailing Address - Country:US
Mailing Address - Phone:360-863-0642
Mailing Address - Fax:360-794-7236
Practice Address - Street 1:101 E MAIN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1519
Practice Address - Country:US
Practice Address - Phone:360-863-0642
Practice Address - Fax:360-794-7236
Is Sole Proprietor?:No
Enumeration Date:2011-12-09
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60255489225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist