Provider Demographics
NPI:1174568778
Name:AYCOCK, KATHLEEN MARY (ARNP, NNP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARY
Last Name:AYCOCK
Suffix:
Gender:F
Credentials:ARNP, NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:909 N BROADWAY
Mailing Address - Street 2:PBO
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-1409
Mailing Address - Country:US
Mailing Address - Phone:425-317-0264
Mailing Address - Fax:425-317-0291
Practice Address - Street 1:900 PACIFIC AVE
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4168
Practice Address - Country:US
Practice Address - Phone:425-304-6040
Practice Address - Fax:425-304-6045
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30005772363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP27014Medicare UPIN
WAGAB29337Medicare PIN
WAG8878187Medicare PIN