Provider Demographics
NPI:1063749497
Name:WOJEWODA, KIM OLIVER (LMP)
Entity type:Individual
Prefix:MRS
First Name:KIM
Middle Name:OLIVER
Last Name:WOJEWODA
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 1:2095 NE NELSON LN
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98029-3670
Mailing Address - Country:US
Mailing Address - Phone:425-996-3095
Mailing Address - Fax:
Practice Address - Street 1:670 NW GILMAN BLVD STE B2
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-2444
Practice Address - Country:US
Practice Address - Phone:425-427-6562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-05
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020152225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist