Provider Demographics
NPI:1942418322
Name:KELLY, DUYANE LEWIS (LMP)
Entity Type:Individual
Prefix:MR
First Name:DUYANE
Middle Name:LEWIS
Last Name:KELLY
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12116 SE MILL PLAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-6000
Mailing Address - Country:US
Mailing Address - Phone:360-256-5253
Mailing Address - Fax:360-256-5081
Practice Address - Street 1:12116 SE MILL PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-6000
Practice Address - Country:US
Practice Address - Phone:360-256-5253
Practice Address - Fax:360-256-5081
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00019384225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist