Provider Demographics
NPI:1720314065
Name:MASSINGHAM, KIRSTY A
Entity Type:Individual
Prefix:
First Name:KIRSTY
Middle Name:A
Last Name:MASSINGHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIRSTEN
Other - Middle Name:A
Other - Last Name:HARKER-MASSINGHAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMP
Mailing Address - Street 1:2107 DRIFTWOOD PL
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98363-5117
Mailing Address - Country:US
Mailing Address - Phone:360-457-6175
Mailing Address - Fax:
Practice Address - Street 1:1215 E 1ST ST STE E
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-4323
Practice Address - Country:US
Practice Address - Phone:360-417-1153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-21
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60118155225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist