Provider Demographics
NPI:1003313222
Name:KIENZLE, DEVON REESE (DO)
Entity Type:Individual
Prefix:
First Name:DEVON
Middle Name:REESE
Last Name:KIENZLE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 E KINCAID ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1190 RIDDLE ST
Practice Address - Street 2:
Practice Address - City:DARRINGTON
Practice Address - State:WA
Practice Address - Zip Code:98241-7722
Practice Address - Country:US
Practice Address - Phone:360-436-1055
Practice Address - Fax:360-436-0146
Is Sole Proprietor?:No
Enumeration Date:2018-04-13
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP61073204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine