Provider Demographics
NPI:1629594601
Name:MCINTIRE, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MCINTIRE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3629 S D ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98418-6813
Mailing Address - Country:US
Mailing Address - Phone:253-798-4745
Mailing Address - Fax:
Practice Address - Street 1:3701 PACIFIC AVE STE 200
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98418-7838
Practice Address - Country:US
Practice Address - Phone:253-255-8385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-21
Last Update Date:2017-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00104973163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health