Provider Demographics
NPI:1417466871
Name:BERTUCCI, KIMBERLY JOHNS (DNP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JOHNS
Last Name:BERTUCCI
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:L
Other - Last Name:JOHNS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1802 YAKIMA AVE STE 302
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-5305
Mailing Address - Country:US
Mailing Address - Phone:253-627-1244
Mailing Address - Fax:253-627-6576
Practice Address - Street 1:1802 YAKIMA AVE STE 302
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-5305
Practice Address - Country:US
Practice Address - Phone:253-627-1244
Practice Address - Fax:253-627-6576
Is Sole Proprietor?:No
Enumeration Date:2017-09-28
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP09547363LF0000X
WAAP61550203363LA2200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2458370Medicaid
WA2289912Medicaid