Healthcare Provider Details

I. General information

NPI: 1124149521
Provider Name (Legal Business Name): KRISTEN LYNE HURSH LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 RACQUET LN
YAKIMA WA
98902-6114
US

IV. Provider business mailing address

260 ADOBE WAY
SELAH WA
98942-9081
US

V. Phone/Fax

Practice location:
  • Phone: 509-452-5155
  • Fax: 509-452-5355
Mailing address:
  • Phone: 509-452-5155
  • Fax: 509-452-5355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMA00015704
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: