Healthcare Provider Details

I. General information

NPI: 1588091151
Provider Name (Legal Business Name): MARTINA KOWALKE LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2013
Last Update Date: 09/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 W NORTH BEND WAY
NORTH BEND WA
98045-8150
US

IV. Provider business mailing address

1618 STONE CREEK CIR SW
NORTH BEND WA
98045-9127
US

V. Phone/Fax

Practice location:
  • Phone: 832-948-0625
  • Fax: 425-292-0402
Mailing address:
  • Phone: 832-948-0625
  • Fax: 425-292-0402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA 60381693
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: