Provider Demographics
NPI:1770790297
Name:WEDDLE, KIMBERLY JEAN (LMP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JEAN
Last Name:WEDDLE
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:PO BOX 1087
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98009-1087
Mailing Address - Country:US
Mailing Address - Phone:425-422-3406
Mailing Address - Fax:
Practice Address - Street 1:14042 NE 8TH ST
Practice Address - Street 2:SUITE 206
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007-4142
Practice Address - Country:US
Practice Address - Phone:425-422-3406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00016090225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0199271OtherLABOR AND INDUSTRIES