Provider Demographics
NPI:1679884761
Name:LANGE, KELLY ELIZABETH (NP-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ELIZABETH
Last Name:LANGE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3125 OLD FAIRHAVEN PKWY STE 106
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-8266
Mailing Address - Country:US
Mailing Address - Phone:360-788-8388
Mailing Address - Fax:360-788-8389
Practice Address - Street 1:3125 OLD FAIRHAVEN PKWY STE 106
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-8266
Practice Address - Country:US
Practice Address - Phone:360-788-8388
Practice Address - Fax:360-788-8389
Is Sole Proprietor?:No
Enumeration Date:2010-06-23
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN104462-AP06137363LF0000X
WAAP61473911363LF0000X
MO2011036223363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAP61473911OtherARNP LICENSE
LAAP003393OtherSTATE LICENSE