Provider Demographics
NPI:1114451994
Name:SCOTT, KALISSA
Entity Type:Individual
Prefix:
First Name:KALISSA
Middle Name:
Last Name:SCOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98901-3020
Mailing Address - Country:US
Mailing Address - Phone:509-454-4143
Mailing Address - Fax:509-454-4115
Practice Address - Street 1:12 S 8TH ST
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98901-3020
Practice Address - Country:US
Practice Address - Phone:509-454-4143
Practice Address - Fax:509-454-4115
Is Sole Proprietor?:No
Enumeration Date:2017-04-18
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00174359171M00000X, 163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator