Provider Demographics
NPI:1306880430
Name:FARRELL, KIM (MD)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:FARRELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:ELISABETH
Other - Last Name:FARRELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:15811 AMBAUM BLVD SW
Mailing Address - Street 2:SUITE 170
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98166-3066
Mailing Address - Country:US
Mailing Address - Phone:206-439-2988
Mailing Address - Fax:206-431-3939
Practice Address - Street 1:10030 SW 210TH ST
Practice Address - Street 2:
Practice Address - City:VASHON
Practice Address - State:WA
Practice Address - Zip Code:98070-6584
Practice Address - Country:US
Practice Address - Phone:206-463-3671
Practice Address - Fax:206-463-3613
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00036422207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG96765Medicare UPIN