Healthcare Provider Details

I. General information

NPI: 1437355153
Provider Name (Legal Business Name): LAURA SAMPLE COYKENDALL PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURA GERTRUDE SAMPLE PT

II. Dates (important events)

Enumeration Date: 06/21/2007
Last Update Date: 01/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19319 7TH AVE NE STE 108
POULSBO WA
98370-7442
US

IV. Provider business mailing address

2012 NW KIMBALL RD
POULSBO WA
98370-9571
US

V. Phone/Fax

Practice location:
  • Phone: 360-779-3777
  • Fax: 360-779-3797
Mailing address:
  • Phone: 360-697-1279
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT00003870
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code2251E1300X
TaxonomyClinical Electrophysiology Physical Therapist
License NumberPT0003870
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License NumberPT0003870
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code2251H1200X
TaxonomyHand Physical Therapist
License NumberPT0003870
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: