Basic Information
| Provider Information | |||||||||
| NPI: | 1215422928 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIENEKER | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | CATHLEEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 660 S COOLIDGE ST | ||||||||
| Address2: | |||||||||
| City: | MOSES LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988371872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 0979397155 | ||||||||
| FaxNumber: | 5097643244 | ||||||||
| Practice Location | |||||||||
| Address1: | 8420 ASPI BLVD | ||||||||
| Address2: | |||||||||
| City: | MOSES LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988373601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5097939781 | ||||||||
| FaxNumber: | 5097643281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2018 | ||||||||
| LastUpdateDate: | 08/31/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | TRN27403 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD61130841 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2179902 | 05 | WA | MEDICAID |