Provider Demographics
NPI:1467911800
Name:GULLICKSON, KELSEY
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:GULLICKSON
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 1:4444 175TH PL SE
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98006-6513
Mailing Address - Country:US
Mailing Address - Phone:425-643-3423
Mailing Address - Fax:
Practice Address - Street 1:1633 WESTLAKE AVE N STE 105
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109-6241
Practice Address - Country:US
Practice Address - Phone:206-802-9515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-15
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60904899363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAP60904899OtherWASHINGTON STATE NURSE PRACTITIONER LICENSE