Provider Demographics
NPI:1649041468
Name:ADDY, KIMBERLEY LYNN
Entity type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:LYNN
Last Name:ADDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4715 42ND AVE SW APT 306
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98116-4620
Mailing Address - Country:US
Mailing Address - Phone:509-270-7661
Mailing Address - Fax:
Practice Address - Street 1:6307 CALIFORNIA AVE SW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98136-1892
Practice Address - Country:US
Practice Address - Phone:206-902-7608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61408282225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist