Healthcare Provider Details

I. General information

NPI: 1083892665
Provider Name (Legal Business Name): WENDY KAY KELLAM PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: WENDY K JACKSON

II. Dates (important events)

Enumeration Date: 02/05/2008
Last Update Date: 10/14/2020
Certification Date: 10/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2811 NE 139TH ST
VANCOUVER WA
98686-2724
US

IV. Provider business mailing address

PO BOX 4825
PORTLAND OR
97208-4825
US

V. Phone/Fax

Practice location:
  • Phone: 360-574-5247
  • Fax:
Mailing address:
  • Phone: 360-882-2778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60638000
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA164630
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: