Provider Demographics
NPI:1417943630
Name:TIMMONS, KELLY A (MD PHD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:TIMMONS
Suffix:
Gender:F
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 SUMMITVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-2715
Mailing Address - Country:US
Mailing Address - Phone:509-574-6000
Mailing Address - Fax:509-225-2714
Practice Address - Street 1:1470 N 16TH AVE
Practice Address - Street 2:SUITE D
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-1381
Practice Address - Country:US
Practice Address - Phone:509-574-6000
Practice Address - Fax:509-225-2714
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM10053207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00715305BMedicaid
ID807841500Medicaid
GA00715305BMedicaid
ID20002186Medicare PIN