Provider Demographics
NPI:1174779656
Name:VICKERY, KIMBERLY ANN (LMP)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANN
Last Name:VICKERY
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12710 OLD MILITARY RD NE
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-7984
Mailing Address - Country:US
Mailing Address - Phone:360-440-5471
Mailing Address - Fax:360-377-6401
Practice Address - Street 1:5060 HIGHWAY 303 NE
Practice Address - Street 2:SUITE 103
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98311
Practice Address - Country:US
Practice Address - Phone:360-377-6335
Practice Address - Fax:360-377-6401
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-15
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00019934174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist