Healthcare Provider Details

I. General information

NPI: 1790057438
Provider Name (Legal Business Name): KACEY WIMMER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KACEY BRODIE PA-C

II. Dates (important events)

Enumeration Date: 01/26/2012
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 E ST NW L209
WASHINGTON DC
20520-5712
US

IV. Provider business mailing address

2401 E ST NW L209
WASHINGTON DC
20520-5712
US

V. Phone/Fax

Practice location:
  • Phone: 202-792-3826
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA200002199
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA156855
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: