Basic Information
Provider Information | |||||||||
NPI: | 1194244889 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KETTEL | ||||||||
FirstName: | LAURA | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4040 ORCHARD ST W STE 100 | ||||||||
Address2: |   | ||||||||
City: | FIRCREST | ||||||||
State: | WA | ||||||||
PostalCode: | 984666610 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9516969353 | ||||||||
FaxNumber: | 9519737216 | ||||||||
Practice Location | |||||||||
Address1: | 34617 11TH PL S STE 201 | ||||||||
Address2: |   | ||||||||
City: | FEDERAL WAY | ||||||||
State: | WA | ||||||||
PostalCode: | 980038706 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2538151117 | ||||||||
FaxNumber: | 2538151107 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/13/2017 | ||||||||
LastUpdateDate: | 06/16/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X |   |   | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | PT60754995 | 01 | WA | PT LICENSURE | OTHER |