Provider Demographics
NPI:1467990861
Name:KENYON, SUMMER
Entity Type:Individual
Prefix:
First Name:SUMMER
Middle Name:
Last Name:KENYON
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 1:5014 S WAPATO ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-7136
Mailing Address - Country:US
Mailing Address - Phone:253-576-9824
Mailing Address - Fax:
Practice Address - Street 1:7504 86TH ST SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98498-6176
Practice Address - Country:US
Practice Address - Phone:253-212-2036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-06
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60658265405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional