Provider Demographics
NPI:1083672406
Name:KELLY, DIANE M (LMP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:M
Last Name:KELLY
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 1:9105 NE 25TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98665-9057
Mailing Address - Country:US
Mailing Address - Phone:360-573-8183
Mailing Address - Fax:
Practice Address - Street 1:7902 NE ST JOHNS RD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98665-1094
Practice Address - Country:US
Practice Address - Phone:360-573-6424
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA0005268174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist