Provider Demographics
NPI:1053647701
Name:RILEY, KELLY (LMP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:RILEY
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 E MAIN AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-6777
Mailing Address - Country:US
Mailing Address - Phone:253-845-2013
Mailing Address - Fax:253-845-2030
Practice Address - Street 1:1011 E MAIN AVE STE 201
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-6777
Practice Address - Country:US
Practice Address - Phone:253-845-2013
Practice Address - Fax:253-845-2030
Is Sole Proprietor?:No
Enumeration Date:2009-10-29
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00015467174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA00015467OtherSTATE LICENSE