Provider Demographics
NPI:1588715957
Name:PROCTOR, KRISTINE MARIE (LMP,MMP)
Entity type:Individual
Prefix:MRS
First Name:KRISTINE
Middle Name:MARIE
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:LMP,MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17118 SE 181ST PL
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98058-8759
Mailing Address - Country:US
Mailing Address - Phone:425-830-8308
Mailing Address - Fax:
Practice Address - Street 1:13210 SE 240TH ST
Practice Address - Street 2:SUITE A-4
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98042-5182
Practice Address - Country:US
Practice Address - Phone:253-631-1118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00018749174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0182527OtherLABOR AND INDUSTRIES