Healthcare Provider Details

I. General information

NPI: 1558637868
Provider Name (Legal Business Name): KELLY L ENFIELD ATC/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2012
Last Update Date: 06/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17050 431ST AVE SE
NORTH BEND WA
98045-9650
US

IV. Provider business mailing address

17026 426TH AVE SE
NORTH BEND WA
98045-9345
US

V. Phone/Fax

Practice location:
  • Phone: 425-736-1475
  • Fax:
Mailing address:
  • Phone: 425-736-1475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: