Provider Demographics
NPI:1396157079
Name:WILBUR, KAYLYNNE JUDITH
Entity type:Individual
Prefix:
First Name:KAYLYNNE
Middle Name:JUDITH
Last Name:WILBUR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7002 S PLYMOUTH RD
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99224-5998
Mailing Address - Country:US
Mailing Address - Phone:509-979-0798
Mailing Address - Fax:
Practice Address - Street 1:826 N MULLAN RD
Practice Address - Street 2:SUITE B
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-4094
Practice Address - Country:US
Practice Address - Phone:509-979-0798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-29
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60466271225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist