Provider Demographics
NPI:1447723846
Name:ALLEN, KIMBERLY ANNE (LMT# 5776)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANNE
Last Name:ALLEN
Suffix:
Gender:F
Credentials:LMT# 5776
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 159
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:OR
Mailing Address - Zip Code:97495-0159
Mailing Address - Country:US
Mailing Address - Phone:541-677-0690
Mailing Address - Fax:
Practice Address - Street 1:338 PIONEER WAY
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:OR
Practice Address - Zip Code:97495-8984
Practice Address - Country:US
Practice Address - Phone:541-677-0690
Practice Address - Fax:541-440-0893
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5776225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR5776OtherMASSAGE THERAPY LICENSE