Basic Information
| Provider Information | |||||||||
| NPI: | 1063468585 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIKILLUS | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT, DSC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEERAR | ||||||||
| OtherFirstName: | PAMELA | ||||||||
| OtherMiddleName: | J | ||||||||
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| OtherCredential: | PT, DSC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9315 GRAVELLY LAKE DR SW | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984991574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535815200 | ||||||||
| FaxNumber: | 2535815203 | ||||||||
| Practice Location | |||||||||
| Address1: | 8011 112TH STREET CT E | ||||||||
| Address2: | |||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983737814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538480662 | ||||||||
| FaxNumber: | 2538488567 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT00005876 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 444955 | 01 | WA | LABOR & INDUSTRIES | OTHER | 8346983 | 05 | WA | MEDICAID | 9605LE | 01 | WA | REGENCE BLUESHIELD | OTHER | 8930578 | 01 | WA | L&I CRIME VICTIMS PROG | OTHER |