Provider Demographics
NPI:1962837575
Name:IKERD, KRISTINA LORRAINE (LMP)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:LORRAINE
Last Name:IKERD
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 12983
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98508-2983
Mailing Address - Country:US
Mailing Address - Phone:360-229-0382
Mailing Address - Fax:
Practice Address - Street 1:4804 LACEY BLVD SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-5733
Practice Address - Country:US
Practice Address - Phone:360-561-0171
Practice Address - Fax:360-915-7857
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-13
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00024258225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist