Provider Demographics
NPI:1255606448
Name:KELLY, ELISEHA ENNEE (LMP)
Entity type:Individual
Prefix:MS
First Name:ELISEHA
Middle Name:ENNEE
Last Name:KELLY
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4651 S FRONTENAC ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98118-3627
Mailing Address - Country:US
Mailing Address - Phone:206-850-6428
Mailing Address - Fax:
Practice Address - Street 1:1812 E MADISON ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-2843
Practice Address - Country:US
Practice Address - Phone:206-850-6428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-20
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60253578174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist