MEDICARE: KIRSTY A MASSINGHAM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	MA60118155	WA

General Provider Information

NPI Number	:	1720314065
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIRSTY A MASSINGHAM

Provider Business Mailing Address
First Line	:	2107 DRIFTWOOD PL
Second Line	:
City	:	PORT ANGELES
State	:	WA
Zip	:	98363-5117
Country	:	US
Telephone Number	:	360-457-6175
Fax Number	:

Provider Business Practice Location Address
First Line	:	1215 E 1ST ST STE E
Second Line	:
City	:	PORT ANGELES
State	:	WA
Zip	:	98362-4323
Country	:	US
Telephone Number	:	360-417-1153
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/21/2009
Last Update Date	:	10/21/2009

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