Provider Demographics
NPI:1154799286
Name:FALLON, KIM
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:FALLON
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:PO BOX 1947
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-1947
Mailing Address - Country:US
Mailing Address - Phone:206-321-8574
Mailing Address - Fax:
Practice Address - Street 1:7825 N SOUND DR
Practice Address - Street 2:
Practice Address - City:SEDRO WOOLLEY
Practice Address - State:WA
Practice Address - Zip Code:98284-7675
Practice Address - Country:US
Practice Address - Phone:510-337-7950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-06
Last Update Date:2015-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP00021365164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse