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General NPI Number Information
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NPI Number | 1073939427
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Entity Type | Organization
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Legal Business Name | KGP LLC
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Dates
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Enumeration Date | 03/10/2014
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Last Update Date | 03/10/2014
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Provider Practice Location Address
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Address Line | 319 E PIONEER AVE
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City | MONTESANO
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State | WA
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Zip | 98563-4601
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Country | US
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Telephone | 360-249-1980
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1898
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City | ABERDEEN
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State | WA
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Zip | 98520-0315
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Country | US
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Telephone | 360-637-9263
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Fax | 360-637-8732
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Authorized Official
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Title or Position | OWNER
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Name | KERRY PETERSON
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Credential | FNP
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Telephone | 360-249-1980
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | AP60443753
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License Number State | WA
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