Provider Demographics
NPI:1528328101
Name:KEREKES, KRISTEN GRACE BRADLEY (ARNP)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:GRACE BRADLEY
Last Name:KEREKES
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:GRACE
Other - Last Name:BRADLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ARNP
Mailing Address - Street 1:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:5300 TALLMAN AVE NW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-3932
Practice Address - Country:US
Practice Address - Phone:206-320-3514
Practice Address - Fax:206-781-6011
Is Sole Proprietor?:No
Enumeration Date:2012-05-17
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61014374363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2149564Medicaid