Basic Information
| Provider Information | |||||||||
| NPI: | 1639159189 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FUNCHESS | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WESSEL | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 19500 10TH AVE NE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | POULSBO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983706553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605987500 | ||||||||
| FaxNumber: | 3605987505 | ||||||||
| Practice Location | |||||||||
| Address1: | 19500 10TH AVE NE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | POULSBO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983706553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605987500 | ||||||||
| FaxNumber: | 3605987505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2006 | ||||||||
| LastUpdateDate: | 02/14/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 3343 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 985608 | 05 | AZ | MEDICAID | PA60322657 | 01 | WA | WASHINGTON STATE LICENSE | OTHER |