Provider Demographics
NPI:1780801795
Name:KUNTZ, MYRA RENAE (LMP)
Entity type:Individual
Prefix:MRS
First Name:MYRA
Middle Name:RENAE
Last Name:KUNTZ
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12506 18TH ST NE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:LAKE STEVENS
Mailing Address - State:WA
Mailing Address - Zip Code:98258
Mailing Address - Country:US
Mailing Address - Phone:425-334-9664
Mailing Address - Fax:
Practice Address - Street 1:15209 3 LAKES RD
Practice Address - Street 2:
Practice Address - City:SNOHOMISH
Practice Address - State:WA
Practice Address - Zip Code:98290-4614
Practice Address - Country:US
Practice Address - Phone:360-568-0813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00015610174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist