Healthcare Provider Details

I. General information

NPI: 1033424239
Provider Name (Legal Business Name): KIRK, SHERRIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2010
Last Update Date: 08/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6470 NE MARSHALL RD
BAINBRIDGE ISLAND WA
98110-1617
US

IV. Provider business mailing address

6470 NE MARSHALL RD
BAINBRIDGE ISLAND WA
98110-1617
US

V. Phone/Fax

Practice location:
  • Phone: 206-819-9605
  • Fax:
Mailing address:
  • Phone: 206-819-9605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberPO0000501
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberPO0000501
License Number StateWA

VIII. Authorized Official

Name: CHARITY CAMPBELL
Title or Position: CREDENTIALING
Credential:
Phone: 425-775-1505