Healthcare Provider Details

I. General information

NPI: 1770157836
Provider Name (Legal Business Name): MARY W KIMANI RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2021
Last Update Date: 09/25/2023
Certification Date: 09/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12607 SE MILL PLAIN BLVD
VANCOUVER WA
98684-4098
US

IV. Provider business mailing address

12607 SE MILL PLAIN BLVD
VANCOUVER WA
98684-4098
US

V. Phone/Fax

Practice location:
  • Phone: 800-813-2000
  • Fax:
Mailing address:
  • Phone: 800-813-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP61477341
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN60502306
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: