Provider Demographics
NPI:1568698421
Name:FLETCHER, KELLIE JEAN (AA)
Entity Type:Individual
Prefix:MS
First Name:KELLIE
Middle Name:JEAN
Last Name:FLETCHER
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3322 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-4425
Mailing Address - Country:US
Mailing Address - Phone:425-349-6871
Mailing Address - Fax:425-349-6855
Practice Address - Street 1:3322 BROADWAY
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4425
Practice Address - Country:US
Practice Address - Phone:425-349-6871
Practice Address - Fax:425-349-6855
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-05
Last Update Date:2009-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC60092654171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator