Provider Demographics
NPI:1457534422
Name:CULVER, KELLY R (LMP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:R
Last Name:CULVER
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 1:407 W 29TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99337-5013
Mailing Address - Country:US
Mailing Address - Phone:509-586-4587
Mailing Address - Fax:888-349-8276
Practice Address - Street 1:407 W 29TH AVE
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99337-5013
Practice Address - Country:US
Practice Address - Phone:509-586-4587
Practice Address - Fax:888-349-8276
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-12
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00018067225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0202335OtherDEPT. OF LABOR AND INDUST
WA0202335OtherDEPT. OF LABOR AND INDUST