Provider Demographics
NPI:1245019207
Name:BURNS, KELLY CLARK
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:CLARK
Last Name:BURNS
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 1:5315 E SILVER PINE RD
Mailing Address - Street 2:
Mailing Address - City:COLBERT
Mailing Address - State:WA
Mailing Address - Zip Code:99005-9574
Mailing Address - Country:US
Mailing Address - Phone:509-230-9573
Mailing Address - Fax:
Practice Address - Street 1:5315 E SILVER PINE RD
Practice Address - Street 2:
Practice Address - City:COLBERT
Practice Address - State:WA
Practice Address - Zip Code:99005-9574
Practice Address - Country:US
Practice Address - Phone:509-230-9573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-27
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAA-3391085171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach