MEDICARE: A COMMUNITY WELLNESS CLINIC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1396118469	OTHER		NPI

General Provider Information

NPI Number	:	1063056497
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A COMMUNITY WELLNESS CLINIC LLC

Provider Business Mailing Address
First Line	:	2405 E 17TH AVE STE 113
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99223-5122
Country	:	US
Telephone Number	:	509-720-8516
Fax Number	:

Provider Business Practice Location Address
First Line	:	2405 E 17TH AVE STE 113
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99223-5122
Country	:	US
Telephone Number	:	509-720-8516
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KERRY LEE TRAUGOTT
Credential	:	DNP
Telephone Number	:	509-720-8516

Provider Enumeration Date	:	10/29/2019
Last Update Date	:	05/13/2026

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Directions to “A COMMUNITY WELLNESS CLINIC LLC ” Practice Location

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