Provider Demographics
NPI:1932913712
Name:OLIVER, KISHA P (MEDICAL PEDICURIST)
Entity type:Individual
Prefix:
First Name:KISHA
Middle Name:P
Last Name:OLIVER
Suffix:
Gender:F
Credentials:MEDICAL PEDICURIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12520 ROOSEVELT WAY NE APT 303
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98125-3948
Mailing Address - Country:US
Mailing Address - Phone:206-501-1264
Mailing Address - Fax:
Practice Address - Street 1:14917 AMBAUM BLVD SW
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-1847
Practice Address - Country:US
Practice Address - Phone:206-501-1264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-03
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAE2100-100167332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies