Basic Information
Provider Information | |||||||||
NPI: | 1821390956 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | YUKEVICH | ||||||||
FirstName: | KELLY | ||||||||
MiddleName: | WILLIAMS | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | ARNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 34888 | ||||||||
Address2: |   | ||||||||
City: | SEATTLE | ||||||||
State: | WA | ||||||||
PostalCode: | 981241888 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4259774620 | ||||||||
FaxNumber: | 4257459836 | ||||||||
Practice Location | |||||||||
Address1: | 21600 HIGHWAY 99 | ||||||||
Address2: | SUITE 260 | ||||||||
City: | EDMONDS | ||||||||
State: | WA | ||||||||
PostalCode: | 980268012 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4257742650 | ||||||||
FaxNumber: | 4257742643 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/22/2010 | ||||||||
LastUpdateDate: | 03/25/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP60197381 | WA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 0299616 | 01 | WA | LABOR AND INDUSTRIES | OTHER | 2013457 | 05 | WA |   | MEDICAID |