Basic Information
| Provider Information | |||||||||
| NPI: | 1821623257 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WICKSTROM | ||||||||
| FirstName: | KIRSTEN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | DNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 920 N 34TH ST APT 36 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981038879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2067157571 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9245 RAINIER AVE S | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981185569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2067228444 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2020 | ||||||||
| LastUpdateDate: | 11/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WM0705X | RN60465203 | WA | N | Nursing Service Providers | Registered Nurse | Medical-Surgical | 363LF0000X | AP61166029 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.