Provider Demographics
NPI:1285635086
Name:FARRELL, KATHLEEN MARIAN (DO)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIAN
Last Name:FARRELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 N 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:SEQUIM
Mailing Address - State:WA
Mailing Address - Zip Code:98382-3045
Mailing Address - Country:US
Mailing Address - Phone:360-683-5900
Mailing Address - Fax:360-582-4800
Practice Address - Street 1:808 N 5TH AVE
Practice Address - Street 2:
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382-3045
Practice Address - Country:US
Practice Address - Phone:360-582-4840
Practice Address - Fax:360-582-4801
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO25860207Q00000X
IDO-364207Q00000X
WAOP60119145207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807209001Medicaid
ID807209001Medicaid
ORR132014Medicare PIN
ID13030323Medicare PIN
I37196Medicare UPIN
ORR132012Medicare PIN
ID13030322Medicare PIN