Provider Demographics
NPI:1093762692
Name:KINYON, HARLEY WREN (CCC-A)
Entity Type:Individual
Prefix:
First Name:HARLEY
Middle Name:WREN
Last Name:KINYON
Suffix:
Gender:M
Credentials:CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9621 RIDGETOP BLVD NW
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-8502
Mailing Address - Country:US
Mailing Address - Phone:360-830-1204
Mailing Address - Fax:
Practice Address - Street 1:2200 NW MYHRE RD
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-7681
Practice Address - Country:US
Practice Address - Phone:360-830-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACD00002516237600000X
WACD000025516231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
640004426OtherRAILROAD MEDICARE
WA7108947Medicaid
WA9052556Medicaid
WA158357OtherLABOR & INDUSTRIES
7927357OtherAETNA
8918KIOtherREGENCE BLUE SHIELD
7927357OtherAETNA
WA7108947Medicaid
WA9052556Medicaid