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General NPI Number Information
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NPI Number | 1497723217
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Entity Type | Individual
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Provider Name | KELLY MARIE LANDLE P.A.-C
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Gender | Female
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Dates
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Enumeration Date | 03/08/2006
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Last Update Date | 04/16/2019
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Provider Practice Location Address
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Address Line | 606 E MAIN ST
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City | KENDRICK
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State | ID
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Zip | 83537
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Country | US
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Telephone | 208-289-3841
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Fax | 208-289-3961
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Provider Business Mailing Address
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Address Line | 700 S MAIN ST
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City | MOSCOW
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State | ID
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Zip | 83843-3046
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Country | US
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Telephone | 208-882-4511
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA-345
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | PA10004069
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License Number State | WA
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Taxonomy #3
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA10004069
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License Number State | WA
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