Healthcare Provider Details

I. General information

NPI: 1578177747
Provider Name (Legal Business Name): KELLY JEANE DEYOUNG ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2020
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 S FIFE ST
TACOMA WA
98409-7309
US

IV. Provider business mailing address

3901 S FIFE ST
TACOMA WA
98409-7309
US

V. Phone/Fax

Practice location:
  • Phone: 253-301-6400
  • Fax:
Mailing address:
  • Phone: 253-301-6400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN60089101
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP61462903
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAP61462903
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: