Provider Demographics
NPI:1821746157
Name:EVERETT, KACEY
Entity Type:Individual
Prefix:
First Name:KACEY
Middle Name:
Last Name:EVERETT
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 1:17204 118TH LN SE APT O101
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98058-6233
Mailing Address - Country:US
Mailing Address - Phone:909-237-2693
Mailing Address - Fax:
Practice Address - Street 1:10224 AIRPORT WAY STE A
Practice Address - Street 2:
Practice Address - City:SNOHOMISH
Practice Address - State:WA
Practice Address - Zip Code:98296-8203
Practice Address - Country:US
Practice Address - Phone:360-863-6696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-15
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1689148090OtherNPPES