Provider Demographics
NPI:1629356548
Name:BAXTER, KELLE EVONNE (ARNP)
Entity Type:Individual
Prefix:
First Name:KELLE
Middle Name:EVONNE
Last Name:BAXTER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:747 BROADWAY
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-4379
Practice Address - Country:US
Practice Address - Phone:206-215-9853
Practice Address - Fax:206-215-3636
Is Sole Proprietor?:No
Enumeration Date:2011-07-26
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00114759163WC1600X
WA19915373163WL0100X
WAAP60148511363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC1600XNursing Service ProvidersRegistered NurseContinuing Education/Staff Development
No163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant