Healthcare Provider Details

I. General information

NPI: 1457769408
Provider Name (Legal Business Name): ELIZABETH KELLEY WICHETA ZINKA FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2014
Last Update Date: 04/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2005 W MAIN ST STE 110
BATTLE GROUND WA
98604-4311
US

IV. Provider business mailing address

700 NE 87TH AVE
VANCOUVER WA
98664-4896
US

V. Phone/Fax

Practice location:
  • Phone: 360-882-2778
  • Fax:
Mailing address:
  • Phone: 360-882-2778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024171872
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP60823894
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: