Healthcare Provider Details

I. General information

NPI: 1720805112
Provider Name (Legal Business Name): KIMBERLY OLDHAM RNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2024
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 CAPITAL MALL DR SW STE B
OLYMPIA WA
98502-8654
US

IV. Provider business mailing address

6704 WESTHILL CT SW
OLYMPIA WA
98512-2014
US

V. Phone/Fax

Practice location:
  • Phone: 360-528-8567
  • Fax:
Mailing address:
  • Phone: 908-420-3102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberRN61294934
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: