Provider Demographics
NPI:1710566500
Name:LEVEQUE, KELLY ANN
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANN
Last Name:LEVEQUE
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 1:406 SE 131ST AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-4013
Mailing Address - Country:US
Mailing Address - Phone:360-687-0025
Mailing Address - Fax:877-360-9140
Practice Address - Street 1:406 SE 131ST AVE STE 205
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-4013
Practice Address - Country:US
Practice Address - Phone:360-687-0025
Practice Address - Fax:877-360-9140
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60450910251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health