Basic Information
Provider Information
NPI: 1003152364
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PETERSEN
FirstName: KAYLEE
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: ARNP
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 50095
Address2:  
City: SEATTLE
State: WA
PostalCode: 981455095
CountryCode: US
TelephoneNumber: 2065205700
FaxNumber:  
Practice Location
Address1: 2505 2ND AVE
Address2: SUITE #200
City: SEATTLE
State: WA
PostalCode: 981211452
CountryCode: US
TelephoneNumber: 2064430400
FaxNumber:  
Other Information
ProviderEnumerationDate: 12/13/2012
LastUpdateDate: 12/15/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363LF0000XAP60293083WAY Physician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily

ID Information
IDTypeStateIssuerDescription
100315236405WA MEDICAID


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