Provider Demographics
NPI:1831134600
Name:LARSEN, KELLY KRISTINE (OD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:KRISTINE
Last Name:LARSEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:KRISTINE
Other - Last Name:LUTHY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5566
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98227-5566
Mailing Address - Country:US
Mailing Address - Phone:360-733-1720
Mailing Address - Fax:360-733-0109
Practice Address - Street 1:720 BIRCHWOOD AVE
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1714
Practice Address - Country:US
Practice Address - Phone:360-733-1720
Practice Address - Fax:360-733-0109
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003987152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2031367Medicaid
WA2031367Medicaid
WAG8862273Medicare PIN
WAG8862272Medicare PIN