Healthcare Provider Details

I. General information

NPI: 1770653784
Provider Name (Legal Business Name): KELLY M DALE ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 12/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4420 76TH ST NE
MARYSVILLE WA
98270-3726
US

IV. Provider business mailing address

PO BOX 5127
EVERETT WA
98206-5127
US

V. Phone/Fax

Practice location:
  • Phone: 360-651-7493
  • Fax:
Mailing address:
  • Phone: 425-258-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP30005577
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: