Provider Demographics
NPI:1073605671
Name:POPPE, KIMBERLY RUTH (ARNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:RUTH
Last Name:POPPE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:RUTH
Other - Last Name:HUDSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ARNP
Mailing Address - Street 1:909 N BROADWAY
Mailing Address - Street 2:PBO
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-1409
Mailing Address - Country:US
Mailing Address - Phone:425-317-0699
Mailing Address - Fax:425-317-0291
Practice Address - Street 1:916 PACIFIC AVE
Practice Address - Street 2:FIRST FLOOR
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4147
Practice Address - Country:US
Practice Address - Phone:425-258-7390
Practice Address - Fax:425-258-7379
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30005862363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9631375Medicaid
WAG8877618Medicare PIN
WAP41588Medicare UPIN
WA9631375Medicaid