1134537491 NPI number — KYANN R WISSE PHARMD

Table of content: KYANN R WISSE PHARMD (NPI 1134537491)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134537491 NPI number — KYANN R WISSE PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WISSE
Provider First Name:
KYANN
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134537491
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 25608
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84125-0608
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-320-4476
Provider Business Mailing Address Fax Number:
206-568-7043

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4100 SW ALASKA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98116-4527
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-320-3399
Provider Business Practice Location Address Fax Number:
206-320-5506
Provider Enumeration Date:
07/30/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  PH60372101 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1134537491 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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