Healthcare Provider Details

I. General information

NPI: 1699839803
Provider Name (Legal Business Name): MRS. HEIDI ANN KELLY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 REID ST
TACOMA WA
98431-1100
US

IV. Provider business mailing address

1418 BEECH AVE
STEILACOOM WA
98388-3818
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-4382
  • Fax:
Mailing address:
  • Phone: 253-267-5665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: