1356821128 NPI number — MRS. KAYLA MARIE WEIDERSTROM LMT

Table of content: MRS. KAYLA MARIE WEIDERSTROM LMT (NPI 1356821128)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356821128 NPI number — MRS. KAYLA MARIE WEIDERSTROM LMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEIDERSTROM
Provider First Name:
KAYLA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LMT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356821128
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6805 66TH ST NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARYSVILLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98270-6595
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1101 AVENUE D STE C106
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SNOHOMISH
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98290-2083
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-563-0209
Provider Business Practice Location Address Fax Number:
360-563-0243
Provider Enumeration Date:
08/20/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225700000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225700000X , with the licence number: MA60773869 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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