Provider Demographics
NPI:1306955091
Name:MALLORY, KRISTIN (LMP)
Entity type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:
Last Name:MALLORY
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 1:1221 MOTTMAN RD SW
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98512-0405
Mailing Address - Country:US
Mailing Address - Phone:360-493-8784
Mailing Address - Fax:
Practice Address - Street 1:1221 MOTTMAN RD SW
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512-0405
Practice Address - Country:US
Practice Address - Phone:360-493-8784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00016834225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0200792OtherDEPT OF L&I