Provider Demographics
NPI:1073905741
Name:WITTE, KELLY LORRAINE (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LORRAINE
Last Name:WITTE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:358 N MAIN ST
Mailing Address - Street 2:COLVILLE COMMUNITY HEALTH CLINIC
Mailing Address - City:COLVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:99114-2310
Mailing Address - Country:US
Mailing Address - Phone:509-684-1440
Mailing Address - Fax:509-684-2745
Practice Address - Street 1:358 N MAIN ST
Practice Address - Street 2:COLVILLE COMMUNITY HEALTH CLINIC
Practice Address - City:COLVILLE
Practice Address - State:WA
Practice Address - Zip Code:99114-2310
Practice Address - Country:US
Practice Address - Phone:509-684-1440
Practice Address - Fax:509-684-2745
Is Sole Proprietor?:No
Enumeration Date:2015-03-04
Last Update Date:2017-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WA60697687363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program