Basic Information
| Provider Information | |||||||||
| NPI: | 1811132178 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEYER | ||||||||
| FirstName: | KERRY | ||||||||
| MiddleName: | ELLEN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PETRUCCI | ||||||||
| OtherFirstName: | KERRY | ||||||||
| OtherMiddleName: | ELLEN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 34876 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981241876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256565412 | ||||||||
| FaxNumber: | 4256564096 | ||||||||
| Practice Location | |||||||||
| Address1: | 4033 TALBOT RD S | ||||||||
| Address2: | STE 570 | ||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980555772 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256565400 | ||||||||
| FaxNumber: | 4256565079 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2008 | ||||||||
| LastUpdateDate: | 09/10/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP30003229 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.