Healthcare Provider Details

I. General information

NPI: 1063056497
Provider Name (Legal Business Name): A COMMUNITY WELLNESS CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2019
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2405 E 17TH AVE STE 113
SPOKANE WA
99223-5122
US

IV. Provider business mailing address

2405 E 17TH AVE STE 113
SPOKANE WA
99223-5122
US

V. Phone/Fax

Practice location:
  • Phone: 509-720-8516
  • Fax:
Mailing address:
  • Phone: 509-720-8516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. KERRY LEE TRAUGOTT
Title or Position: OWNER
Credential: DNP
Phone: 509-720-8516