Provider Demographics
NPI:1245048628
Name:BREEDING, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BREEDING
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 1:217 REX AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:CA
Mailing Address - Zip Code:95642-2020
Mailing Address - Country:US
Mailing Address - Phone:206-418-9800
Mailing Address - Fax:
Practice Address - Street 1:217 REX AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95642-2020
Practice Address - Country:US
Practice Address - Phone:209-418-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-18
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker