Provider Demographics
NPI:1669512828
Name:SUDORE, KELLY ANNE (RN, BSN, DC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:SUDORE
Suffix:
Gender:F
Credentials:RN, BSN, DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-1812
Mailing Address - Country:US
Mailing Address - Phone:360-794-4500
Mailing Address - Fax:360-863-1640
Practice Address - Street 1:328 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1812
Practice Address - Country:US
Practice Address - Phone:360-794-4500
Practice Address - Fax:360-863-1640
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORCH00033602111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA402450OtherOTHER
WA402450OtherOTHER
WA8807179Medicare ID - Type UnspecifiedMEDICARE