Provider Demographics
NPI:1053374421
Name:MEMORIAL NEPHROLOGY ASSOCIATES PLLC
Entity type:Organization
Organization Name:MEMORIAL NEPHROLOGY ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MIKKI
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-413-8391
Mailing Address - Street 1:3525 ENSIGN RD NE
Mailing Address - Street 2:SUITE K
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5065
Mailing Address - Country:US
Mailing Address - Phone:360-413-8121
Mailing Address - Fax:360-413-8865
Practice Address - Street 1:3525 ENSIGN RD NE
Practice Address - Street 2:SUITE K
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5065
Practice Address - Country:US
Practice Address - Phone:360-413-8121
Practice Address - Fax:360-413-8865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-07
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB20374Medicare ID - Type Unspecified