Provider Demographics
NPI:1073550281
Name:KANNBERG NYBO, JENNIFER L (OD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:KANNBERG NYBO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30035 34TH AVE S
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98001-2224
Mailing Address - Country:US
Mailing Address - Phone:425-985-8857
Mailing Address - Fax:
Practice Address - Street 1:7724 CENTER BLVD SE
Practice Address - Street 2:
Practice Address - City:SNOQUALMIE
Practice Address - State:WA
Practice Address - Zip Code:98065-8993
Practice Address - Country:US
Practice Address - Phone:425-831-2060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003906152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2029510Medicaid
WA9457KAOtherREGENCE BLUESHIELD
WA753021696OtherPREMERA BLUE CROSS
WA0189397OtherDEPARTMENT OF L & I
WA2029510Medicaid
WA8805707Medicare ID - Type Unspecified