Provider Demographics
NPI:1619261930
Name:LAVENDER, KIMBERLY MARIE (ARNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MARIE
Last Name:LAVENDER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16504 9TH AVE SE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-6396
Mailing Address - Country:US
Mailing Address - Phone:425-977-4620
Mailing Address - Fax:425-745-9836
Practice Address - Street 1:11800 NE 128TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-7208
Practice Address - Country:US
Practice Address - Phone:425-899-4500
Practice Address - Fax:425-899-4510
Is Sole Proprietor?:No
Enumeration Date:2011-06-03
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60585175363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003906300Medicaid
FL003906300Medicaid