Provider Demographics
NPI:1578941522
Name:QUACKENBUSH, KALE (DO)
Entity Type:Individual
Prefix:DR
First Name:KALE
Middle Name:
Last Name:QUACKENBUSH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17700 SE 272ND ST
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98042-4951
Mailing Address - Country:US
Mailing Address - Phone:253-372-6500
Mailing Address - Fax:
Practice Address - Street 1:17700 SE 272ND ST
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:WA
Practice Address - Zip Code:98042-4951
Practice Address - Country:US
Practice Address - Phone:253-372-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-11
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOL60572023207Q00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine