Provider Demographics
NPI:1336413871
Name:KELLY, CYNTHIA ANNE (LMP)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:ANNE
Last Name:KELLY
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 1:625 N 5TH AVE
Mailing Address - Street 2:SUITE #1
Mailing Address - City:SEQUIM
Mailing Address - State:WA
Mailing Address - Zip Code:98382-5062
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:625 N 5TH AVE
Practice Address - Street 2:SUITE #1
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382-5062
Practice Address - Country:US
Practice Address - Phone:360-681-2414
Practice Address - Fax:360-681-7239
Is Sole Proprietor?:No
Enumeration Date:2012-03-01
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00021564225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist