Provider Demographics
NPI:1487186888
Name:PORT OF ANGELS PEDIATRICS, PC
Entity Type:Organization
Organization Name:PORT OF ANGELS PEDIATRICS, PC
Other - Org Name:PORT OF ANGELS PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KALLI
Authorized Official - Middle Name:MAE
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:CPNP
Authorized Official - Phone:360-460-9493
Mailing Address - Street 1:2844 W EDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98363-9510
Mailing Address - Country:US
Mailing Address - Phone:615-618-3812
Mailing Address - Fax:
Practice Address - Street 1:2844 W EDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98363-9510
Practice Address - Country:US
Practice Address - Phone:615-618-3812
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-03
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60691562363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty