Provider Demographics
NPI:1831340702
Name:MCKINLEY, DIANE CARI (LMP)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:CARI
Last Name:MCKINLEY
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 1:217 BOZARTH HEIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98674-9217
Mailing Address - Country:US
Mailing Address - Phone:360-225-4807
Mailing Address - Fax:
Practice Address - Street 1:12504 NW 36TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98685-2227
Practice Address - Country:US
Practice Address - Phone:360-573-5611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-09
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00011518225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist