Provider Demographics
NPI:1770157836
Name:KIMANI, MARY W (RN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:W
Last Name:KIMANI
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12607 SE MILL PLAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-4098
Mailing Address - Country:US
Mailing Address - Phone:800-813-2000
Mailing Address - Fax:
Practice Address - Street 1:12607 SE MILL PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-4098
Practice Address - Country:US
Practice Address - Phone:800-813-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-13
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60502306163W00000X
WAAP61477341363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse