Healthcare Provider Details

I. General information

NPI: 1770192924
Provider Name (Legal Business Name): PENNIE KHONG NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2020
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33501 1ST WAY S
FEDERAL WAY WA
98003-6208
US

IV. Provider business mailing address

PO BOX 741515
LOS ANGELES CA
90074-1515
US

V. Phone/Fax

Practice location:
  • Phone: 253-838-2400
  • Fax: 253-874-1637
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP61090460
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: