Provider Demographics
NPI:1487045449
Name:DEFFENBAUGH, KELSI LYNN (CNA)
Entity Type:Individual
Prefix:
First Name:KELSI
Middle Name:LYNN
Last Name:DEFFENBAUGH
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1845
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98668-1845
Mailing Address - Country:US
Mailing Address - Phone:360-397-8484
Mailing Address - Fax:360-397-8494
Practice Address - Street 1:1601 E 4TH PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-3753
Practice Address - Country:US
Practice Address - Phone:360-397-8484
Practice Address - Fax:360-397-8494
Is Sole Proprietor?:No
Enumeration Date:2015-02-12
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANC60384141171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator