Healthcare Provider Details

I. General information

NPI: 1083762207
Provider Name (Legal Business Name): CONNIE J KLAGGE PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1809 100TH PL SE
EVERETT WA
98208-3829
US

IV. Provider business mailing address

10805 39TH DR SE
EVERETT WA
98208-5428
US

V. Phone/Fax

Practice location:
  • Phone: 425-357-1809
  • Fax: 425-357-8519
Mailing address:
  • Phone: 425-357-1809
  • Fax: 425-357-8519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberPT00005242
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: