Healthcare Provider Details

I. General information

NPI: 1063898112
Provider Name (Legal Business Name): NICOLE KUYKENDALL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2015
Last Update Date: 05/04/2020
Certification Date: 05/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 PETERSON RD
BURLINGTON WA
98233-2606
US

IV. Provider business mailing address

1475 SW PONSTEEN DR
OAK HARBOR WA
98277-5818
US

V. Phone/Fax

Practice location:
  • Phone: 360-856-3054
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH60901009
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: