Healthcare Provider Details

I. General information

NPI: 1124151824
Provider Name (Legal Business Name): LAUREN MAY WICKEN KUNTZ L.M.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LAUREN MAY WICKEN L.M.P.

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 NORTH BEND WAY
NORTH BEND WA
98045
US

IV. Provider business mailing address

1270 E NORTH BEND WAY UNIT 22
NORTH BEND WA
98045-9512
US

V. Phone/Fax

Practice location:
  • Phone: 425-888-5060
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00021520
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: