Provider Demographics
NPI:1316922586
Name:BURGESS, KATHLEEN MARIE (ARNP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:BURGESS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1117 TIETON DR
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-3835
Mailing Address - Country:US
Mailing Address - Phone:866-904-7721
Mailing Address - Fax:529-522-1940
Practice Address - Street 1:828 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-4003
Practice Address - Country:US
Practice Address - Phone:866-904-7721
Practice Address - Fax:509-522-1940
Is Sole Proprietor?:No
Enumeration Date:2005-12-10
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30003165363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP31080Medicare UPIN