Provider Demographics
NPI:1275539256
Name:POOLE, KIMBERLEE ELIZABETH
Entity Type:Individual
Prefix:
First Name:KIMBERLEE
Middle Name:ELIZABETH
Last Name:POOLE
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 1:660 S COOLIDGE ST
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-1872
Mailing Address - Country:US
Mailing Address - Phone:509-793-9715
Mailing Address - Fax:509-764-3244
Practice Address - Street 1:1550 S PIONEER WAY STE 200
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-4614
Practice Address - Country:US
Practice Address - Phone:509-793-9787
Practice Address - Fax:509-764-3263
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30006565363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1275539256Medicaid
WA0235658OtherL&I
WA314892OtherL&I POST 7/21/13
WAP01256552OtherRR MEDICARE
WA1275539256Medicaid
WAG8920334, G8920335Medicare PIN