Provider Demographics
NPI:1821773656
Name:ELEAZER, KELLIE ALLYN
Entity Type:Individual
Prefix:MRS
First Name:KELLIE
Middle Name:ALLYN
Last Name:ELEAZER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:A
Other - Last Name:KOGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9330 59TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-2858
Mailing Address - Country:US
Mailing Address - Phone:253-620-5015
Mailing Address - Fax:253-620-5140
Practice Address - Street 1:9330 59TH AVE SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-2858
Practice Address - Country:US
Practice Address - Phone:253-620-5015
Practice Address - Fax:253-620-5140
Is Sole Proprietor?:No
Enumeration Date:2023-06-20
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program