Basic Information
| Provider Information | |||||||||
| NPI: | 1154491280 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NOLLETTE | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 122 W 7TH AVE | ||||||||
| Address2: | 450 | ||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992042349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094558820 | ||||||||
| FaxNumber: | 5098384978 | ||||||||
| Practice Location | |||||||||
| Address1: | 122 W 7TH AVE | ||||||||
| Address2: | 450 | ||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992042349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094558820 | ||||||||
| FaxNumber: | 5098384978 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 06/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN00114221 | WA | N | Nursing Service Providers | Registered Nurse | 363L00000X | AP30005685 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 805843200 | 05 | ID | MEDICAID | 9628207 | 05 | WA | MEDICAID |