Healthcare Provider Details

I. General information

NPI: 1609049774
Provider Name (Legal Business Name): JONATHON LUTHER KELLY IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2008
Last Update Date: 04/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BOONE RD NAVAL HOSPITAL BREMERTON
BREMERTON WA
98312-1894
US

IV. Provider business mailing address

1 BOONE RD NAVAL HOSPITAL BREMERTON
BREMERTON WA
98312-1894
US

V. Phone/Fax

Practice location:
  • Phone: 360-475-4841
  • Fax: 360-475-4935
Mailing address:
  • Phone: 360-475-4841
  • Fax: 360-475-4935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: