Provider Demographics
NPI:1982829867
Name:KIMBER, LATAWN MICHELLE (LMP)
Entity Type:Individual
Prefix:
First Name:LATAWN
Middle Name:MICHELLE
Last Name:KIMBER
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:LATAWN
Other - Middle Name:MICHELLE
Other - Last Name:HARDMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:4209 CANDLEWOOD DR SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-4423
Mailing Address - Country:US
Mailing Address - Phone:360-556-8089
Mailing Address - Fax:
Practice Address - Street 1:4315 6TH AVE SE STE D
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1041
Practice Address - Country:US
Practice Address - Phone:360-556-8089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60237823211225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist