Provider Demographics
NPI:1902041254
Name:VANWINKLE-KOEPPEN, KERRY LEXENE (LMP)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:LEXENE
Last Name:VANWINKLE-KOEPPEN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 ROOSEVELT AVE STE A
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-2646
Mailing Address - Country:US
Mailing Address - Phone:360-428-0304
Mailing Address - Fax:360-428-0968
Practice Address - Street 1:1600 ROOSEVELT AVE STE A
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-2646
Practice Address - Country:US
Practice Address - Phone:360-428-0304
Practice Address - Fax:360-428-0968
Is Sole Proprietor?:No
Enumeration Date:2008-12-15
Last Update Date:2008-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00025185174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist