Provider Demographics
NPI:1932687704
Name:YELLOW BRICK CLINIC PLLC
Entity Type:Organization
Organization Name:YELLOW BRICK CLINIC PLLC
Other - Org Name:YELLOW BRICK CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, PMHNP, FNP,PMHS
Authorized Official - Phone:425-777-5467
Mailing Address - Street 1:DO NOT PUBLISH
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98056-2715
Mailing Address - Country:US
Mailing Address - Phone:425-736-9609
Mailing Address - Fax:833-631-6941
Practice Address - Street 1:DO NOT PUBLISH
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98056-2715
Practice Address - Country:US
Practice Address - Phone:425-777-5467
Practice Address - Fax:833-631-6941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-02
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363L00000X, 363LF0000X, 363LP0200X, 363LP0808X
WAAP60786815363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2090206Medicaid