Provider Demographics
NPI:1073939427
Name:KGP LLC
Entity Type:Organization
Organization Name:KGP LLC
Other - Org Name:KERRY PETERSON FNP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:360-249-1980
Mailing Address - Street 1:PO BOX 1898
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:WA
Mailing Address - Zip Code:98520-0315
Mailing Address - Country:US
Mailing Address - Phone:360-637-9263
Mailing Address - Fax:360-637-8732
Practice Address - Street 1:319 E PIONEER AVE
Practice Address - Street 2:
Practice Address - City:MONTESANO
Practice Address - State:WA
Practice Address - Zip Code:98563-4601
Practice Address - Country:US
Practice Address - Phone:360-249-1980
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-10
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60443753363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty