Healthcare Provider Details

I. General information

NPI: 1154452399
Provider Name (Legal Business Name): KIMBERLY HERNDON LMP, RC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12727 NORTHUP WAY
BELLEVUE WA
98005-1917
US

IV. Provider business mailing address

1616 NEWPORT AVE NE
RENTON WA
98056-3231
US

V. Phone/Fax

Practice location:
  • Phone: 206-683-2851
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00020993
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: