1508209420 NPI number — MS. TERRI LYNN KILBOURNE MA 00004895

Table of content: MS. TERRI LYNN KILBOURNE MA 00004895 (NPI 1508209420)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508209420 NPI number — MS. TERRI LYNN KILBOURNE MA 00004895

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KILBOURNE
Provider First Name:
TERRI
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MA 00004895
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KILBOURNE
Provider Other First Name:
TERRI
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MA 00004895
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1508209420
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/10/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
62408 FOREST GLEN WAY E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ENUMCLAW
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98022-8088
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-663-0260
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1710 RAILROAD STREET
Provider Second Line Business Practice Location Address:
ENUMCLAW DAY SPA
Provider Business Practice Location Address City Name:
ENUMCLAW
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98022
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-825-5755
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/10/2013

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: 174400000X , with the licence number:  MA 00004895 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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