Provider Demographics
NPI:1710599758
Name:KELLY KNICKERBOCKER ARNP PLLC
Entity Type:Organization
Organization Name:KELLY KNICKERBOCKER ARNP PLLC
Other - Org Name:KELLY KNICKERBOCKER ARNP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:SWANSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-954-3330
Mailing Address - Street 1:20126 BALLINGER WAY NE
Mailing Address - Street 2:PMB 89
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98155-1117
Mailing Address - Country:US
Mailing Address - Phone:425-954-3330
Mailing Address - Fax:425-249-3107
Practice Address - Street 1:23007 LAKEVIEW DRIVE
Practice Address - Street 2:A203
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-1117
Practice Address - Country:US
Practice Address - Phone:425-954-3330
Practice Address - Fax:425-249-3107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-20
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1427304138OtherPROVIDER NPI (NPI 1)