Provider Demographics
NPI:1730659236
Name:KIMANI, BENADETA
Entity Type:Individual
Prefix:
First Name:BENADETA
Middle Name:
Last Name:KIMANI
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 1:2150 FREEMAN RD E
Mailing Address - Street 2:
Mailing Address - City:FIFE
Mailing Address - State:WA
Mailing Address - Zip Code:98424-3776
Mailing Address - Country:US
Mailing Address - Phone:253-942-5644
Mailing Address - Fax:253-235-5216
Practice Address - Street 1:2150 FREEMAN RD E
Practice Address - Street 2:
Practice Address - City:FIFE
Practice Address - State:WA
Practice Address - Zip Code:98424-3776
Practice Address - Country:US
Practice Address - Phone:253-942-5644
Practice Address - Fax:253-235-5216
Is Sole Proprietor?:No
Enumeration Date:2018-11-28
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP60702761164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse