Healthcare Provider Details

I. General information

NPI: 1093762692
Provider Name (Legal Business Name): HARLEY WREN KINYON CCC-A
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 03/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 NW MYHRE RD
SILVERDALE WA
98383-7681
US

IV. Provider business mailing address

9621 RIDGETOP BLVD NW
SILVERDALE WA
98383-8502
US

V. Phone/Fax

Practice location:
  • Phone: 360-830-1100
  • Fax:
Mailing address:
  • Phone: 360-830-1204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License NumberCD00002516
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberCD000025516
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: