Healthcare Provider Details

I. General information

NPI: 1760964316
Provider Name (Legal Business Name): KELSEY WARDLOW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2018
Last Update Date: 01/24/2023
Certification Date: 01/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 188TH ST S
SPANAWAY WA
98387-4618
US

IV. Provider business mailing address

134 188TH ST S
SPANAWAY WA
98387-4618
US

V. Phone/Fax

Practice location:
  • Phone: 253-847-2304
  • Fax:
Mailing address:
  • Phone: 253-847-2304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60887650
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: