Provider Demographics
NPI:1629124870
Name:KELLEY, KATIE (LMP, RC)
Entity Type:Individual
Prefix:MS
First Name:KATIE
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:LMP, RC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5821 S FLETCHER ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98118-6009
Mailing Address - Country:US
Mailing Address - Phone:206-528-8032
Mailing Address - Fax:206-528-5807
Practice Address - Street 1:5505 30TH AVE NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-5501
Practice Address - Country:US
Practice Address - Phone:206-528-8043
Practice Address - Fax:206-528-5807
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00006704174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist