Healthcare Provider Details

I. General information

NPI: 1114372836
Provider Name (Legal Business Name): KIMBERLY WELLS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2016
Last Update Date: 03/18/2025
Certification Date: 03/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 MARTIN LUTHER KING JR WAY
TACOMA WA
98405-4234
US

IV. Provider business mailing address

PO BOX 5299 MS: 820-5-PCO
TACOMA WA
98415-0299
US

V. Phone/Fax

Practice location:
  • Phone: 253-403-1418
  • Fax: 253-403-5955
Mailing address:
  • Phone: 253-459-8231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License Number297724
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberMD61274189
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: