Healthcare Provider Details

I. General information

NPI: 1275748220
Provider Name (Legal Business Name): KELLY ELLEN KAFKA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY ELLEN LESPERANCE M.D.

II. Dates (important events)

Enumeration Date: 05/12/2007
Last Update Date: 06/21/2022
Certification Date: 06/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 JACKSON AVE
TACOMA WA
98431-0001
US

IV. Provider business mailing address

9040 JACKSON AVE
TACOMA WA
98431-0001
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-2252
  • Fax:
Mailing address:
  • Phone: 253-968-2252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number75893
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2007011381
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number2007011381
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: