Healthcare Provider Details

I. General information

NPI: 1013664556
Provider Name (Legal Business Name): KIMBERLY COLLERAN HULSE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2022
Last Update Date: 03/04/2022
Certification Date: 03/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21108 ORVILLE RD E
ORTING WA
98360-9764
US

IV. Provider business mailing address

21108 ORVILLE RD E
ORTING WA
98360-9764
US

V. Phone/Fax

Practice location:
  • Phone: 253-376-8604
  • Fax:
Mailing address:
  • Phone: 253-376-8604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN61074348
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: