Provider Demographics
NPI:1568846558
Name:KRAFT, KELLI (MN, ARNP, FNP-BC)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:KRAFT
Suffix:
Gender:F
Credentials:MN, ARNP, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 E. KINCAID STREET
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4127
Mailing Address - Country:US
Mailing Address - Phone:360-814-6724
Mailing Address - Fax:
Practice Address - Street 1:1190 RIDDLE STREET
Practice Address - Street 2:
Practice Address - City:DARRINGTON
Practice Address - State:WA
Practice Address - Zip Code:98241-9824
Practice Address - Country:US
Practice Address - Phone:360-436-1055
Practice Address - Fax:360-436-0146
Is Sole Proprietor?:No
Enumeration Date:2015-07-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO991572363L00000X
WAAP60673672363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO999999OtherMEDICARE AND MEDICAID APPLICATIONS PENDING
WA2074607Medicaid