Provider Demographics
NPI:1760425201
Name:KELLY, MICHAEL C (NP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:KELLY
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5007
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98509-5007
Mailing Address - Country:US
Mailing Address - Phone:800-599-0166
Mailing Address - Fax:
Practice Address - Street 1:413 LILLY RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5133
Practice Address - Country:US
Practice Address - Phone:360-491-9480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30006322363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
8906877OtherWA CRIME VICTIMS
6059KEOtherREGENCE BS
199382OtherWA L & I
WA9635574Medicaid
G8855107Medicare PIN
8906877OtherWA CRIME VICTIMS