Provider Demographics
NPI:1063898112
Name:KUYKENDALL, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:KUYKENDALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1475 SW PONSTEEN DR
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98277-5818
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:614 PETERSON RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98233-2606
Practice Address - Country:US
Practice Address - Phone:360-856-3054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-30
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60901009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health