Provider Demographics
NPI:1124151824
Name:WICKEN KUNTZ, LAUREN MAY (LMP)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:MAY
Last Name:WICKEN KUNTZ
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:MAY
Other - Last Name:WICKEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:1270 E NORTH BEND WAY UNIT 22
Mailing Address - Street 2:
Mailing Address - City:NORTH BEND
Mailing Address - State:WA
Mailing Address - Zip Code:98045-9512
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:410 NORTH BEND WAY
Practice Address - Street 2:
Practice Address - City:NORTH BEND
Practice Address - State:WA
Practice Address - Zip Code:98045
Practice Address - Country:US
Practice Address - Phone:425-888-5060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00021520225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist