Healthcare Provider Details

I. General information

NPI: 1780421677
Provider Name (Legal Business Name): MICHELLE LYNN KILPATRICK LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2024
Last Update Date: 07/09/2024
Certification Date: 07/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2705 E BURNSIDE ST STE 213
PORTLAND OR
97214-1768
US

IV. Provider business mailing address

8770 SW ILLAHEE CT APT 301
WILSONVILLE OR
97070-8488
US

V. Phone/Fax

Practice location:
  • Phone: 503-234-4288
  • Fax:
Mailing address:
  • Phone: 210-836-7842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT125940
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number27450
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: