Provider Demographics
NPI:1013664333
Name:KELLY, CONSTANCE ANN
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:ANN
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CONSTANCE
Other - Middle Name:ANN
Other - Last Name:JORDAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DH
Mailing Address - Street 1:240 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-2609
Mailing Address - Country:US
Mailing Address - Phone:360-452-7891
Mailing Address - Fax:360-452-8087
Practice Address - Street 1:933 E 1ST ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-4012
Practice Address - Country:US
Practice Address - Phone:360-452-7891
Practice Address - Fax:360-452-8087
Is Sole Proprietor?:No
Enumeration Date:2022-03-07
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH00000979124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist