Provider Demographics
NPI:1396541124
Name:SAMUELSON, KIMBERLY (FNP-C)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:SAMUELSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:HUCKLEBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9909 168TH ST E STE 102
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98375-2513
Mailing Address - Country:US
Mailing Address - Phone:253-445-3000
Mailing Address - Fax:
Practice Address - Street 1:9909 168TH ST E STE 102
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98375-2513
Practice Address - Country:US
Practice Address - Phone:253-445-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-21
Last Update Date:2025-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61570680363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner