Healthcare Provider Details

I. General information

NPI: 1205932191
Provider Name (Legal Business Name): KELLY JEAN HALL DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 08/07/2025
Certification Date: 08/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12900 NE 180TH ST STE 150
BOTHELL WA
98011-5778
US

IV. Provider business mailing address

12900 NE 180TH ST STE 150
BOTHELL WA
98011-5778
US

V. Phone/Fax

Practice location:
  • Phone: 206-365-5484
  • Fax: 206-365-5714
Mailing address:
  • Phone: 206-365-5484
  • Fax: 206-365-5714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPO00000617
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1106699
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer
# 2
Identifier5815682
Identifier TypeOTHER
Identifier StateWA
Identifier IssuerAETNA
# 3
IdentifierHA0967
Identifier TypeOTHER
Identifier StateWA
Identifier IssuerREGENCE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: