=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881173490
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALICIA BETH KIDD APRN, PMHNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2018
-----------------------------------------------------
Last Update Date | 01/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 203 W PATISON ST STE B
-----------------------------------------------------
City | PORT HADLOCK
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98339-8701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-251-0898
-----------------------------------------------------
Fax | 360-251-0863
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6780 HORIZON RD STE 102
-----------------------------------------------------
City | HEATH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75032-2104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-877-6395
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | AP61190565
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------