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Individual

KETARAE ANN KONSHUK

Active
Sole proprietor
Yes

Provider details

NPI number
Gender
F
Credential
LMP

Contact information

Practice address
619 W HAZEL ST, MOUNT VERNON, WA 98273-4827
(360) 610-1693
Mailing address
619 WEST HAZEL, MOUNT VERNON, WA 98273
(360) 610-1693

Taxonomy

Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
MA-19764
WA

Other

Enumeration date
05/16/2007
Last updated
07/08/2007
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