Healthcare Provider Details

I. General information

NPI: 1902640105
Provider Name (Legal Business Name): BONTU GUDETA KENTIBA ARNP
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2024
Last Update Date: 10/19/2025
Certification Date: 10/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 WOODLAND SQUARE LOOP SE
LACEY WA
98503-1045
US

IV. Provider business mailing address

4410 GALLAGHER WAY NW
OLYMPIA WA
98502-9005
US

V. Phone/Fax

Practice location:
  • Phone: 360-764-8000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP70057059
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: