Provider Demographics
NPI:1528438132
Name:OKAMOTO, KRISTINE (LMT)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:OKAMOTO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3940 SE BROOKLYN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-1627
Mailing Address - Country:US
Mailing Address - Phone:503-267-6479
Mailing Address - Fax:
Practice Address - Street 1:3940 SE BROOKLYN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1627
Practice Address - Country:US
Practice Address - Phone:503-267-6479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-25
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18240171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor