Provider Demographics
NPI:1720351000
Name:KAUTZMANN, MICHELLE TERI
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:TERI
Last Name:KAUTZMANN
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 1:1714 ANN ST NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-3470
Mailing Address - Country:US
Mailing Address - Phone:360-480-0196
Mailing Address - Fax:
Practice Address - Street 1:5500 MARTIN WAY E
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-6326
Practice Address - Country:US
Practice Address - Phone:360-456-4057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-16
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00043285183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6013270Medicaid
WA0154160170Medicare UPIN