Healthcare Provider Details

I. General information

NPI: 1861357139
Provider Name (Legal Business Name): PETERSON KINYUA IRERI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2025
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7700 300TH ST NW
STANWOOD WA
98292-5841
US

IV. Provider business mailing address

3520 19TH ST
EVERETT WA
98201-2669
US

V. Phone/Fax

Practice location:
  • Phone: 360-209-8426
  • Fax: 360-474-4024
Mailing address:
  • Phone: 206-556-8022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN61546578
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: