Basic Information
| Provider Information | |||||||||
| NPI: | 1568516219 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JANNISON DARCEY | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | G. | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2420 S UNION AVE | ||||||||
| Address2: | STE 200 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984051322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532728148 | ||||||||
| FaxNumber: | 2534040506 | ||||||||
| Practice Location | |||||||||
| Address1: | 3209 S 23RD ST | ||||||||
| Address2: | SUITE 340 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984051602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532725127 | ||||||||
| FaxNumber: | 2532720811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 04/08/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA10003817 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 8349045 | 05 | WA | MEDICAID |