Provider Demographics
NPI:1801036041
Name:ADAMS, KELLY JEAN (LPN, RN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN
Last Name:ADAMS
Suffix:
Gender:F
Credentials:LPN, RN
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:JEAN
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1160 NW KATHLEEN DR
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98277-9289
Mailing Address - Country:US
Mailing Address - Phone:360-632-3059
Mailing Address - Fax:
Practice Address - Street 1:1160 NW KATHLEEN DR
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-9289
Practice Address - Country:US
Practice Address - Phone:360-632-3059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-28
Last Update Date:2009-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60076144163W00000X
WALP00059279164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse