Provider Demographics
NPI:1104044098
Name:GILLROY, KELLEY ANN (DPM)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:ANN
Last Name:GILLROY
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 LILLY RD NE STE A
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5086
Mailing Address - Country:US
Mailing Address - Phone:360-438-9092
Mailing Address - Fax:360-438-3906
Practice Address - Street 1:165 LILLY RD NE STE A
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5086
Practice Address - Country:US
Practice Address - Phone:360-438-9092
Practice Address - Fax:604-383-9063
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0677213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ428205Medicaid