Healthcare Provider Details

I. General information

NPI: 1396973400
Provider Name (Legal Business Name): KIMBERLY LYNN PRINE LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2009
Last Update Date: 12/08/2021
Certification Date: 12/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3510 STEELHAMMER DR
CENTRALIA WA
98531-4551
US

IV. Provider business mailing address

3510 STEELHAMMER DR
CENTRALIA WA
98531-4551
US

V. Phone/Fax

Practice location:
  • Phone: 360-623-8020
  • Fax: 360-736-3139
Mailing address:
  • Phone: 360-623-8020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberNA00183242
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60097045
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: