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General NPI Number Information
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NPI Number | 1700412319
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Entity Type | Individual
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Provider Name | KELLY BLAKE EBRAHIMI DO
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Gender | Female
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Dates
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Enumeration Date | 03/14/2020
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Last Update Date | 08/14/2024
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Provider Practice Location Address
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Address Line | 9040 JACKSON AVE
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City | TACOMA
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State | WA
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Zip | 98431-5001
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Country | US
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Telephone | 253-968-2252
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Fax |
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Provider Business Mailing Address
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Address Line | 1 JARRETT WHITE RD
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City | TRIPLER ARMY MEDICAL CENTER
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State | HI
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Zip | 96859-5001
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Country | US
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Telephone |
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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 | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | DOS-2292
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License Number State | HI
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Taxonomy #2
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | DOS-2292
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License Number State | HI
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Taxonomy #3
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | OP61575651
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License Number State | WA
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