Provider Demographics
NPI:1740202514
Name:HERNER, KIMBERLEY K (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:K
Last Name:HERNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 LIND AVE SW
Mailing Address - Street 2:SUITE 100 ATTN CREDENTIALING
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-4970
Mailing Address - Country:US
Mailing Address - Phone:425-690-2715
Mailing Address - Fax:
Practice Address - Street 1:27500 168TH PL SE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:WA
Practice Address - Zip Code:98042-5563
Practice Address - Country:US
Practice Address - Phone:256-903-4304
Practice Address - Fax:425-690-9430
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00032100207VX0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1045456Medicaid
WAG8891459OtherMEDICARE - VALLEY MEDICAL GROUP
WAG13565Medicare UPIN