Provider Demographics
NPI:1679349401
Name:STEPHENSON, KYNNERA (AGPCNP-BC)
Entity type:Individual
Prefix:
First Name:KYNNERA
Middle Name:
Last Name:STEPHENSON
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1913 S AINSWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-3108
Mailing Address - Country:US
Mailing Address - Phone:253-468-6524
Mailing Address - Fax:
Practice Address - Street 1:7808 PACIFIC AVE STE 4
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98408-7039
Practice Address - Country:US
Practice Address - Phone:253-474-3329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-04
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61507659363L00000X, 363LG0600X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology