=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124848106
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KALANDA ADCOCK LPN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2024
-----------------------------------------------------
Last Update Date | 10/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2405 S 300TH ST
-----------------------------------------------------
City | FEDERAL WAY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98003-4225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-945-4409
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 33117 35TH AVE SW
-----------------------------------------------------
City | FEDERAL WAY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98023-2661
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-273-0708
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | LP61309582
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------