Healthcare Provider Details

I. General information

NPI: 1063396687
Provider Name (Legal Business Name): SAMANTHA KELLY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2025
Last Update Date: 08/05/2025
Certification Date: 08/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1536 N 115TH ST STE 130
SEATTLE WA
98133-8416
US

IV. Provider business mailing address

1536 N 115TH ST STE 130
SEATTLE WA
98133-8416
US

V. Phone/Fax

Practice location:
  • Phone: 206-598-3344
  • Fax: 206-598-1250
Mailing address:
  • Phone: 206-598-3344
  • Fax: 206-598-1250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number60284200
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: