Healthcare Provider Details

I. General information

NPI: 1184617052
Provider Name (Legal Business Name): KIRSTIE L THARGE LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: KIRSTIE L JACKSON LMP

II. Dates (important events)

Enumeration Date: 08/25/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21806 103RD AVENUE CT E #202
GRAHAM WA
98338-8115
US

IV. Provider business mailing address

PO BOX 731269
PUYALLUP WA
98373-0060
US

V. Phone/Fax

Practice location:
  • Phone: 253-847-3700
  • Fax: 253-847-9622
Mailing address:
  • Phone: 253-840-2313
  • Fax: 253-840-6340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00016405
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: