Provider Demographics
NPI:1215422928
Name:KIENEKER, LISA CATHLEEN (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:CATHLEEN
Last Name:KIENEKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:660 S COOLIDGE ST
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-1872
Mailing Address - Country:US
Mailing Address - Phone:097-939-7155
Mailing Address - Fax:509-764-3244
Practice Address - Street 1:8420 ASPI BLVD
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-3601
Practice Address - Country:US
Practice Address - Phone:509-793-9781
Practice Address - Fax:509-764-3281
Is Sole Proprietor?:No
Enumeration Date:2018-06-25
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN27403207Q00000X
WAMD61130841207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2179902Medicaid