Provider Demographics
NPI:1720196264
Name:EVANS, KELLY NICOLE (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:NICOLE
Last Name:EVANS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 SAND POINT WAY NE
Mailing Address - Street 2:M/S W7847, BOX 5371, CRANIOFACIAL CTR.
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-3901
Mailing Address - Country:US
Mailing Address - Phone:206-854-0754
Mailing Address - Fax:
Practice Address - Street 1:1959 NE PACIFIC ST
Practice Address - Street 2:C-212, BOX 356340
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-6340
Practice Address - Country:US
Practice Address - Phone:206-543-0065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAML20008094208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics