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General NPI Number Information
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NPI Number | 1992912331
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Entity Type | Individual
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Provider Name | KETARAE ANN KONSHUK LMP
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Gender | Female
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Dates
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Enumeration Date | 05/16/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 619 W HAZEL ST
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City | MOUNT VERNON
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State | WA
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Zip | 98273-4827
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Country | US
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Telephone | 360-610-1693
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Fax |
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Provider Business Mailing Address
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Address Line | 619 WEST HAZEL
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City | MOUNT VERNON
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State | WA
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Zip | 98273
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Country | US
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Telephone | 360-610-1693
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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 | MA-19764
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License Number State | WA
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