Healthcare Provider Details

I. General information

NPI: 1447283064
Provider Name (Legal Business Name): KIMBERLEY ELIZABETH WENGROVE N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 07/29/2022
Certification Date: 07/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 E 4TH PLAIN BLVD V3-HBPC
VANCOUVER WA
98661
US

IV. Provider business mailing address

36006 BRYANT DR SW
ALBANY OR
97321-1853
US

V. Phone/Fax

Practice location:
  • Phone: 360-905-1749
  • Fax: 360-690-0343
Mailing address:
  • Phone: 303-895-7076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number77745
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License Number77745
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number77745
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number77745
License Number StateCO
# 5
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number77745
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: