Provider Demographics
NPI:1932269313
Name:WILSON, KIMBERLY MICHELLE (LMP AND LAC)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:MICHELLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMP AND LAC
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:MICHELLE
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:1800 COOKS HILL RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531
Mailing Address - Country:US
Mailing Address - Phone:360-736-2853
Mailing Address - Fax:360-736-4159
Practice Address - Street 1:1800 COOKS HILL RD
Practice Address - Street 2:SUITE A
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531
Practice Address - Country:US
Practice Address - Phone:360-736-2853
Practice Address - Fax:360-736-4159
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA13686225700000X
WAAC60241994171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist