Provider Demographics
NPI:1699839803
Name:KELLY, HEIDI ANN
Entity Type:Individual
Prefix:MRS
First Name:HEIDI
Middle Name:ANN
Last Name:KELLY
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 1:1418 BEECH AVE
Mailing Address - Street 2:
Mailing Address - City:STEILACOOM
Mailing Address - State:WA
Mailing Address - Zip Code:98388-3818
Mailing Address - Country:US
Mailing Address - Phone:253-267-5665
Mailing Address - Fax:
Practice Address - Street 1:9040 REID ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-1100
Practice Address - Country:US
Practice Address - Phone:253-968-4382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health