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General NPI Number Information
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NPI Number | 1679341762
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Entity Type | Individual
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Provider Name | KIMMISHA JACKSON ROYAL
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Gender | Female
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Dates
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Enumeration Date | 12/18/2023
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Last Update Date | 12/18/2023
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Provider Practice Location Address
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Address Line | 9600 VETERANS DR SW
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City | TACOMA
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State | WA
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Zip | 98493-6638
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Country | US
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Telephone | 253-582-8440
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Fax | 253-589-4143
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Provider Business Mailing Address
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Address Line | 9712 18TH AVENUE CT S APT R14
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City | TACOMA
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State | WA
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Zip | 98444-6638
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Country | US
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Telephone | 253-355-7097
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 164W00000X
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Taxonomy Name | Licensed Practical Nurse
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License Number | 61492022
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License Number State | WA
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