Provider Demographics
NPI:1497302103
Name:AMICONE, KAITLIN
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:AMICONE
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 1:520 TERRY AVE UNIT 728
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-2452
Mailing Address - Country:US
Mailing Address - Phone:330-931-9428
Mailing Address - Fax:
Practice Address - Street 1:34716 1ST AVE S
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6760
Practice Address - Country:US
Practice Address - Phone:253-517-7058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-19
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60963712363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily