Provider Demographics
NPI:1104641083
Name:GOUGH, KYLIE JO
Entity type:Individual
Prefix:MS
First Name:KYLIE
Middle Name:JO
Last Name:GOUGH
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 1:5523 SEAVIEW AVE NW STE A
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98107-3381
Mailing Address - Country:US
Mailing Address - Phone:517-745-2744
Mailing Address - Fax:
Practice Address - Street 1:5410 NE WINDERMERE RD
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-2161
Practice Address - Country:US
Practice Address - Phone:517-745-2744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-18
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28269452A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse