Provider Demographics
NPI:1508057845
Name:KELLY, DAVID M (CP)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:KELLY
Suffix:
Gender:M
Credentials:CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 116TH AVE NE STE 201
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3013
Mailing Address - Country:US
Mailing Address - Phone:425-451-8831
Mailing Address - Fax:425-450-1598
Practice Address - Street 1:1900 116TH AVE NE STE 201
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3013
Practice Address - Country:US
Practice Address - Phone:425-451-8831
Practice Address - Fax:425-450-1598
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPS00000347224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8405789Medicaid