Provider Demographics
NPI:1891105730
Name:KELLY, ANNA R
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:R
Last Name:KELLY
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 1:2508 W SYLVESTER ST STE E
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-4500
Mailing Address - Country:US
Mailing Address - Phone:509-859-9058
Mailing Address - Fax:
Practice Address - Street 1:2508 W SYLVESTER ST STE E
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-4500
Practice Address - Country:US
Practice Address - Phone:509-859-9058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-30
Last Update Date:2018-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60442154174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist