Provider Demographics
NPI:1669619201
Name:RUNKEL, MEGAN KRISTINE (LMP)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:KRISTINE
Last Name:RUNKEL
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 1:125 JEFF DAVIS AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:MS
Mailing Address - Zip Code:39560-6134
Mailing Address - Country:US
Mailing Address - Phone:228-313-9208
Mailing Address - Fax:228-868-4991
Practice Address - Street 1:125 JEFF DAVIS AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:MS
Practice Address - Zip Code:39560-6134
Practice Address - Country:US
Practice Address - Phone:228-313-9208
Practice Address - Fax:228-868-4991
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-20
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2645225700000X
WAMA 60018937174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No174400000XOther Service ProvidersSpecialist