Provider Demographics
NPI:1760964316
Name:WARDLOW, KELSEY
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:WARDLOW
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 1:134 188TH ST S
Mailing Address - Street 2:
Mailing Address - City:SPANAWAY
Mailing Address - State:WA
Mailing Address - Zip Code:98387-4618
Mailing Address - Country:US
Mailing Address - Phone:253-847-2304
Mailing Address - Fax:
Practice Address - Street 1:134 188TH ST S
Practice Address - Street 2:
Practice Address - City:SPANAWAY
Practice Address - State:WA
Practice Address - Zip Code:98387-4618
Practice Address - Country:US
Practice Address - Phone:253-847-2304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60887650363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant