Healthcare Provider Details

I. General information

NPI: 1790466738
Provider Name (Legal Business Name): KIMBERLY DAJANNA HENRIQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2023
Last Update Date: 07/31/2023
Certification Date: 07/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 NE CAMPUS PKWY
SEATTLE WA
98195-0003
US

IV. Provider business mailing address

10018 8TH AVE NE
SEATTLE WA
98125-7406
US

V. Phone/Fax

Practice location:
  • Phone: 206-543-2100
  • Fax:
Mailing address:
  • Phone: 410-564-6953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN61050114
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: