Healthcare Provider Details

I. General information

NPI: 1609571702
Provider Name (Legal Business Name): CYNTHIA M M KELLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CYNTHIA M KELLEY CERT.MEDICAL INTER

II. Dates (important events)

Enumeration Date: 03/30/2023
Last Update Date: 04/07/2023
Certification Date: 04/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 E SAINT ANDREWS DR
SHELTON WA
98584-9666
US

IV. Provider business mailing address

440 E SAINT ANDREWS DR
SHELTON WA
98584-9666
US

V. Phone/Fax

Practice location:
  • Phone: 619-245-7668
  • Fax:
Mailing address:
  • Phone: 619-245-7668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171R00000X
TaxonomyInterpreter
License Number5674
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: