Provider Demographics
NPI:1356795363
Name:CLUNE, KISHA M (MD)
Entity type:Individual
Prefix:
First Name:KISHA
Middle Name:M
Last Name:CLUNE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:21911 76TH AVE W STE 110
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-7918
Practice Address - Country:US
Practice Address - Phone:425-640-4950
Practice Address - Fax:425-640-4958
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-15
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD608749272084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1356795363Medicaid