Provider Demographics
NPI:1205932191
Name:HALL, KELLY JEAN (DPM)
Entity type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:JEAN
Last Name:HALL
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17191 BOTHELL WAY NE
Mailing Address - Street 2:STE. 103
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98155-5534
Mailing Address - Country:US
Mailing Address - Phone:206-365-5484
Mailing Address - Fax:206-365-5714
Practice Address - Street 1:17191 BOTHELL WAY NE
Practice Address - Street 2:STE. 103
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98155-5534
Practice Address - Country:US
Practice Address - Phone:206-365-5484
Practice Address - Fax:206-365-5714
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO00000617213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5815682OtherAETNA
WA1106699Medicaid
WAHA0967OtherREGENCE
WAGAB07692Medicare PIN
U73916Medicare UPIN
WA5815682OtherAETNA