Provider Demographics
NPI:1790554053
Name:MART, KELLENE R
Entity Type:Individual
Prefix:
First Name:KELLENE
Middle Name:R
Last Name:MART
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 1:2500 W SIMS WAY STE 300
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-2234
Mailing Address - Country:US
Mailing Address - Phone:360-385-0610
Mailing Address - Fax:360-379-8259
Practice Address - Street 1:2500 W SIMS WAY STE 300
Practice Address - Street 2:
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368-2234
Practice Address - Country:US
Practice Address - Phone:360-385-0610
Practice Address - Fax:360-379-8259
Is Sole Proprietor?:No
Enumeration Date:2023-12-28
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00177570163WH1000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WH1000XNursing Service ProvidersRegistered NurseHospice