Provider Demographics
NPI:1639159189
Name:FUNCHESS, KIMBERLY LYNN (PA)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:LYNN
Last Name:FUNCHESS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:WESSEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19500 10TH AVE NE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-6553
Mailing Address - Country:US
Mailing Address - Phone:360-598-7500
Mailing Address - Fax:360-598-7505
Practice Address - Street 1:19500 10TH AVE NE
Practice Address - Street 2:SUITE 100
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-6553
Practice Address - Country:US
Practice Address - Phone:360-598-7500
Practice Address - Fax:360-598-7505
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3343363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ985608Medicaid
WAPA60322657OtherWASHINGTON STATE LICENSE
WAPA60322657OtherWASHINGTON STATE LICENSE