Provider Demographics
NPI:1083892665
Name:KELLAM, WENDY KAY (PAC)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:KAY
Last Name:KELLAM
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:K
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 4825
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4825
Mailing Address - Country:US
Mailing Address - Phone:360-882-2778
Mailing Address - Fax:
Practice Address - Street 1:2811 NE 139TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-2724
Practice Address - Country:US
Practice Address - Phone:360-574-5247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-05
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
ORPA164630363AM0700X
WAPA60638000363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1083892665Medicaid
OR500663009Medicaid
WA1083892665Medicaid