Provider Demographics
NPI:1336474766
Name:DETIENNE, KRISTEN (LMT)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:DETIENNE
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 1:6646 SW CAPITOL HWY APT 2
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-1953
Mailing Address - Country:US
Mailing Address - Phone:503-593-1969
Mailing Address - Fax:
Practice Address - Street 1:9055 SW BEAVERTON HILLSDALE HWY STE A
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-2438
Practice Address - Country:US
Practice Address - Phone:503-644-4664
Practice Address - Fax:503-644-9005
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-02
Last Update Date:2009-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16383174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR16383OtherLICENSE