Basic Information
| Provider Information | |||||||||
| NPI: | 1063524080 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERGQUIST | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7244 E MERCER WAY | ||||||||
| Address2: | |||||||||
| City: | MERCER ISLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980405817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062324806 | ||||||||
| FaxNumber: | 4253538041 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 S 43RD ST | ||||||||
| Address2: | |||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980555714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253533588 | ||||||||
| FaxNumber: | 4253538041 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 07/15/2013 | ||||||||
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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 | 163W00000X | RN00042447 | WA | N | Nursing Service Providers | Registered Nurse | 367500000X | AP30004852 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 363L00000X | AP30004852 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 0046242 | 01 | WA | LABOR AND INSDUSTRIES | OTHER | 9610106 | 05 | WA | MEDICAID |