Provider Demographics
NPI:1801513734
Name:IVERSON, KIMBERLY MARIE (ARNP)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:MARIE
Last Name:IVERSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 FAIRBAIRN RD
Mailing Address - Street 2:
Mailing Address - City:MONTESANO
Mailing Address - State:WA
Mailing Address - Zip Code:98563-9740
Mailing Address - Country:US
Mailing Address - Phone:360-581-0559
Mailing Address - Fax:
Practice Address - Street 1:815 K ST
Practice Address - Street 2:
Practice Address - City:HOQUIAM
Practice Address - State:WA
Practice Address - Zip Code:98550-3705
Practice Address - Country:US
Practice Address - Phone:360-537-6430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-21
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61371987207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAP61371987OtherWA STATE DOH CREDENTIAL