Provider Demographics
NPI:1235939265
Name:STAFFORD, KEILA MARIE (MA61656832)
Entity type:Individual
Prefix:
First Name:KEILA
Middle Name:MARIE
Last Name:STAFFORD
Suffix:
Gender:
Credentials:MA61656832
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2775 STATE ROUTE 9
Mailing Address - Street 2:
Mailing Address - City:SEDRO WOOLLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98284-7626
Mailing Address - Country:US
Mailing Address - Phone:360-333-2586
Mailing Address - Fax:
Practice Address - Street 1:112 MORRIS ST
Practice Address - Street 2:SUITE C
Practice Address - City:LA CONNER
Practice Address - State:WA
Practice Address - Zip Code:98257-7015
Practice Address - Country:US
Practice Address - Phone:360-333-2586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-18
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61656832225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist