Basic Information
| Provider Information | |||||||||
| NPI: | 1134166911 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANCHELL | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 742997 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900742997 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605142142 | ||||||||
| FaxNumber: | 3605146820 | ||||||||
| Practice Location | |||||||||
| Address1: | 475 S COLUMBIA RIVER HWY | ||||||||
| Address2: | |||||||||
| City: | SAINT HELENS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970512859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033978040 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 06/30/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA157622 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 8357915 | 05 | WA | MEDICAID |