Provider Demographics
NPI:1043265309
Name:MAY, KATHLEEN J (FNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:J
Last Name:MAY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:J
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:201 TAHOMA BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:YELM
Mailing Address - State:WA
Mailing Address - Zip Code:98597-7735
Mailing Address - Country:US
Mailing Address - Phone:360-458-7761
Mailing Address - Fax:
Practice Address - Street 1:201 TAHOMA BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:YELM
Practice Address - State:WA
Practice Address - Zip Code:98597-7735
Practice Address - Country:US
Practice Address - Phone:360-458-7761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30003033363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA100674OtherL&I
WA9614991Medicaid
WAMA7851OtherREGENCE
AB07108Medicare ID - Type Unspecified
WA9614991Medicaid