Provider Demographics
NPI:1972021434
Name:KELLY, KAITLIN M (PA-C)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:M
Last Name:KELLY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 POINT FOSDICK DR STE 102
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335-1706
Mailing Address - Country:US
Mailing Address - Phone:253-853-2050
Mailing Address - Fax:253-853-2711
Practice Address - Street 1:4700 POINT FOSDICK DR STE 102
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-1706
Practice Address - Country:US
Practice Address - Phone:253-853-2050
Practice Address - Fax:253-853-2711
Is Sole Proprietor?:No
Enumeration Date:2017-09-05
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
WAPA60796422363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2088986Medicaid