Provider Demographics
NPI:1497376115
Name:KMIECHICK, LAUREN
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:KMIECHICK
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 1:35002 PACIFIC HWY S STE 105
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-8365
Mailing Address - Country:US
Mailing Address - Phone:253-944-1289
Mailing Address - Fax:
Practice Address - Street 1:35002 PACIFIC HWY S STE 105
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-8365
Practice Address - Country:US
Practice Address - Phone:253-944-1289
Practice Address - Fax:253-944-1292
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-05
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60804900163W00000X
WAAP61094879363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse