Provider Demographics
NPI:1588080097
Name:HUDSON, KELLY R (LPN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:R
Last Name:HUDSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:R
Other - Last Name:BRYANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:121 WHITESELL ST
Mailing Address - Street 2:ORTING SCHOOL DISTRICT
Mailing Address - City:ORTING
Mailing Address - State:WA
Mailing Address - Zip Code:98360
Mailing Address - Country:US
Mailing Address - Phone:360-893-6500
Mailing Address - Fax:360-893-2300
Practice Address - Street 1:805 OLD PIONEER WAY NORTH
Practice Address - Street 2:PTARMIGAN RIDGE
Practice Address - City:ORTING
Practice Address - State:WA
Practice Address - Zip Code:98360
Practice Address - Country:US
Practice Address - Phone:360-893-0595
Practice Address - Fax:360-893-0603
Is Sole Proprietor?:No
Enumeration Date:2014-03-07
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP60303592164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse