Healthcare Provider Details

I. General information

NPI: 1194057604
Provider Name (Legal Business Name): RUTH KEHELEY BURNETT LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2010
Last Update Date: 03/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

818 39TH AVE SW STE A
PUYALLUP WA
98373-3308
US

IV. Provider business mailing address

PO BOX 731245
PUYALLUP WA
98373-0060
US

V. Phone/Fax

Practice location:
  • Phone: 253-841-2200
  • Fax:
Mailing address:
  • Phone: 253-841-2200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMA 60063544
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: