Basic Information
Provider Information | |||||||||
NPI: | 1467460675 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SALES | ||||||||
FirstName: | KIMBERLY | ||||||||
MiddleName: | G | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | ARNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | TROY-SALES | ||||||||
OtherFirstName: | KIMBERLY | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | ARNP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1019 PACIFIC AVE STE 300 | ||||||||
Address2: | ATTN: CREDENTIALING | ||||||||
City: | TACOMA | ||||||||
State: | WA | ||||||||
PostalCode: | 984024488 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2537221540 | ||||||||
FaxNumber: | 2535974556 | ||||||||
Practice Location | |||||||||
Address1: | 1202 MARTIN LUTHER KING JR WAY | ||||||||
Address2: |   | ||||||||
City: | TACOMA | ||||||||
State: | WA | ||||||||
PostalCode: | 984053926 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2534414742 | ||||||||
FaxNumber: | 2534428790 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/03/2006 | ||||||||
LastUpdateDate: | 03/26/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP30002429 | WA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 9623273 | 05 | WA |   | MEDICAID |