Provider Demographics
NPI:1063524080
Name:BERGQUIST, KATHLEEN A (RN)
Entity type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:A
Last Name:BERGQUIST
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7244 E MERCER WAY
Mailing Address - Street 2:
Mailing Address - City:MERCER ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98040-5817
Mailing Address - Country:US
Mailing Address - Phone:206-232-4806
Mailing Address - Fax:425-353-8041
Practice Address - Street 1:400 S 43RD ST
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5714
Practice Address - Country:US
Practice Address - Phone:425-353-3588
Practice Address - Fax:425-353-8041
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00042447163W00000X
WAAP30004852367500000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0046242OtherLABOR AND INSDUSTRIES
WA9610106Medicaid
WA0046242OtherLABOR AND INSDUSTRIES