Provider Demographics
NPI:1578870069
Name:WILLIAMS, KIMBERLY SUE (FNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SUE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:SUE
Other - Last Name:TULL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18040 SW LOWER BOONES FERRY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-7258
Practice Address - Country:US
Practice Address - Phone:503-216-0700
Practice Address - Fax:503-216-0750
Is Sole Proprietor?:No
Enumeration Date:2010-09-07
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP19924207V00000X, 208000000X, 363L00000X
OR201393029NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP01404411OtherRR MEDICARE - PH&S
CANP19924OtherCA. BOARD OF NURSING
OR500667975Medicaid
ORR174286Medicare PIN
ORR174290Medicare PIN
ORR174287Medicare PIN
CANP19924OtherCA. BOARD OF NURSING
OR500667975Medicaid
ORR174288Medicare PIN
ORP01404411OtherRR MEDICARE - PH&S