Healthcare Provider Details

I. General information

NPI: 1629594601
Provider Name (Legal Business Name): KELLY MCINTIRE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2017
Last Update Date: 08/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3701 PACIFIC AVE STE 200
TACOMA WA
98418-7838
US

IV. Provider business mailing address

3629 S D ST
TACOMA WA
98418-6813
US

V. Phone/Fax

Practice location:
  • Phone: 253-255-8385
  • Fax:
Mailing address:
  • Phone: 253-798-4745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN00104973
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: