Provider Demographics
NPI:1164834636
Name:KUMCUR, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KUMCUR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28850 SE 224TH ST
Mailing Address - Street 2:
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038-7707
Mailing Address - Country:US
Mailing Address - Phone:206-399-2057
Mailing Address - Fax:425-413-8015
Practice Address - Street 1:375 MT OLYMPUS DR NW
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-3016
Practice Address - Country:US
Practice Address - Phone:425-392-3301
Practice Address - Fax:425-392-5617
Is Sole Proprietor?:No
Enumeration Date:2014-06-02
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00106925163W00000X
WAA660-4003747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1001CXP-12OtherAGING & DISABILITY SERVICES ADMINISTRATION