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General NPI Number Information
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NPI Number | 1780801795
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Entity Type | Individual
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Provider Name | MYRA RENAE KUNTZ LMP
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Gender | Female
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Dates
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Enumeration Date | 04/19/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 15209 3 LAKES RD
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City | SNOHOMISH
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State | WA
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Zip | 98290-4614
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Country | US
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Telephone | 360-568-0813
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Fax |
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Provider Business Mailing Address
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Address Line | 12506 18TH ST NE SUITE 4
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City | LAKE STEVENS
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State | WA
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Zip | 98258
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Country | US
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Telephone | 425-334-9664
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | MA00015610
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License Number State | WA
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