Healthcare Provider Details

I. General information

NPI: 1003424128
Provider Name (Legal Business Name): KELLY P GRENNER ARNP-FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2020
Last Update Date: 04/20/2021
Certification Date: 03/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10025 NE 186TH ST
BOTHELL WA
98011-3839
US

IV. Provider business mailing address

22850 NE 8TH ST STE 103
SAMMAMISH WA
98074-7256
US

V. Phone/Fax

Practice location:
  • Phone: 425-486-9131
  • Fax: 425-486-9490
Mailing address:
  • Phone: 425-898-0305
  • Fax: 425-898-8825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP61085959
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: