Provider Demographics
NPI:1386728301
Name:VAN ALLEN, KELLY (LMP, LAC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:VAN ALLEN
Suffix:
Gender:F
Credentials:LMP, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 86
Mailing Address - Street 2:
Mailing Address - City:BOW
Mailing Address - State:WA
Mailing Address - Zip Code:98232-0086
Mailing Address - Country:US
Mailing Address - Phone:360-202-3370
Mailing Address - Fax:
Practice Address - Street 1:321 W WASHINGTON ST STE 334
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-3869
Practice Address - Country:US
Practice Address - Phone:360-202-3370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00013415225700000X
WAAC00002957171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Not Answered171100000XOther Service ProvidersAcupuncturist