Healthcare Provider Details

I. General information

NPI: 1386698736
Provider Name (Legal Business Name): CAROL LEE KINZNER ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 12/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1708 YAKIMA AVE SUITE 107
TACOMA WA
98405-5307
US

IV. Provider business mailing address

1708 YAKIMA AVE SUITE 107
TACOMA WA
98405-5307
US

V. Phone/Fax

Practice location:
  • Phone: 253-272-5881
  • Fax: 253-383-0161
Mailing address:
  • Phone: 253-272-5881
  • Fax: 253-383-0161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAP30004242
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP30004242
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: