Healthcare Provider Details

I. General information

NPI: 1811252117
Provider Name (Legal Business Name): KAYLA SUE KOOKER LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2012
Last Update Date: 07/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5050 STATE HWY 303 NE #A101
BREMERTON WA
98311
US

IV. Provider business mailing address

5050 STATE HWY 303 NE #A101
BREMERTON WA
98311
US

V. Phone/Fax

Practice location:
  • Phone: 360-478-9788
  • Fax: 360-405-6255
Mailing address:
  • Phone: 360-478-9788
  • Fax: 360-405-6255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA0229712
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: