Provider Demographics
NPI:1861452534
Name:SUPPLE, KELLY ANNE (MD, MPH)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:ANNE
Last Name:SUPPLE
Suffix:
Gender:F
Credentials:MD, MPH
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Other - Credentials:
Mailing Address - Street 1:1400 E KINCAID ST
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4127
Mailing Address - Country:US
Mailing Address - Phone:360-428-2500
Mailing Address - Fax:360-428-6485
Practice Address - Street 1:3823 - 172ND STREET NE
Practice Address - Street 2:CASCADE SKAGIT HEALTH ALLIANCE
Practice Address - City:ARLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98223
Practice Address - Country:US
Practice Address - Phone:360-657-8700
Practice Address - Fax:360-657-8717
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ME0158162083X0100X
MN102269207P00000X
WAMD603646702083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1861452534Medicaid
WA1861452534Medicaid