Provider Demographics
NPI:1184199804
Name:GOULETTE, KELSEY (PA-C)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:GOULETTE
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 1:5615 DUNBARTON AVE
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-8216
Mailing Address - Country:US
Mailing Address - Phone:509-222-1275
Mailing Address - Fax:509-491-3031
Practice Address - Street 1:3345 39TH ST S STE 1
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-7539
Practice Address - Country:US
Practice Address - Phone:509-222-1275
Practice Address - Fax:509-491-3031
Is Sole Proprietor?:No
Enumeration Date:2018-10-09
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA6761363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant