Provider Demographics
NPI:1215072731
Name:KINNEY, BOYD A (LMP)
Entity type:Individual
Prefix:
First Name:BOYD
Middle Name:A
Last Name:KINNEY
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24060 SE KENT KANGLEY RD
Mailing Address - Street 2:SUITE D100
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038-6801
Mailing Address - Country:US
Mailing Address - Phone:425-433-0123
Mailing Address - Fax:425-433-0733
Practice Address - Street 1:24060 SE KENT KANGLEY RD
Practice Address - Street 2:SUITE D100
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038-6801
Practice Address - Country:US
Practice Address - Phone:425-433-0123
Practice Address - Fax:425-433-0733
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00018856225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA300112284212OtherPREMERA BLUE CROSS IN
WA32011135806OtherUNIFORM MEDICAL INSURANCE
WA8054KIOtherREGENCE BLUE SHIELD
WA0216782OtherAETNA INSURANCE
WA0182251OtherDEPT OF L&I