Provider Demographics
NPI:1356041032
Name:KICINSKI, KRISTEN MARIE
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MARIE
Last Name:KICINSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 LILLY RD NE STE C
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5080
Mailing Address - Country:US
Mailing Address - Phone:360-918-8336
Mailing Address - Fax:
Practice Address - Street 1:200 LILLY RD NE STE C
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5080
Practice Address - Country:US
Practice Address - Phone:360-918-8336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-09
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61494885363LP0808X
WARN60662619163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse