Healthcare Provider Details

I. General information

NPI: 1457185233
Provider Name (Legal Business Name): KELCEY WEBSTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2024
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3021 GRIFFIN AVE
ENUMCLAW WA
98022-2369
US

IV. Provider business mailing address

2331 YORK RD STE 100
TIMONIUM MD
21093-2246
US

V. Phone/Fax

Practice location:
  • Phone: 360-825-6511
  • Fax:
Mailing address:
  • Phone: 667-668-2566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110011909
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: