Provider Demographics
NPI:1104286921
Name:SOARES-KAKULU, KALENA ANNA (LMT)
Entity type:Individual
Prefix:
First Name:KALENA
Middle Name:ANNA
Last Name:SOARES-KAKULU
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:
Other - Last Name:PEREZ-SANTIAGO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:8839 DAFFODIL LN SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98513-1767
Mailing Address - Country:US
Mailing Address - Phone:360-706-9204
Mailing Address - Fax:
Practice Address - Street 1:7503 144TH ST E
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98375-8269
Practice Address - Country:US
Practice Address - Phone:360-970-6309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-07
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAM00022974174400000X
WAMA00022974225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1104286921Medicaid