Healthcare Provider Details

I. General information

NPI: 1700544681
Provider Name (Legal Business Name): KRISTIN DEWEERD CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2021
Last Update Date: 03/04/2022
Certification Date: 03/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2205 W LINCOLN AVE
YAKIMA WA
98902-2437
US

IV. Provider business mailing address

2205 W LINCOLN AVE
YAKIMA WA
98902-2437
US

V. Phone/Fax

Practice location:
  • Phone: 509-575-1990
  • Fax: 509-469-2185
Mailing address:
  • Phone: 509-469-6305
  • Fax: 509-575-3398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP61250328
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberARNP.AP.61250328-NP
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: