Healthcare Provider Details

I. General information

NPI: 1003280959
Provider Name (Legal Business Name): KELLY HIGDON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2015
Last Update Date: 11/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1012 E 1ST AVE
CAMAS WA
98607-1625
US

IV. Provider business mailing address

1012 E 1ST AVE
CAMAS WA
98607-1625
US

V. Phone/Fax

Practice location:
  • Phone: 360-936-2247
  • Fax:
Mailing address:
  • Phone: 360-936-2247
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN60529555
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: