Provider Demographics
NPI:1700120540
Name:KELLEY, MARY CAROLINE (NP)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:CAROLINE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 162
Mailing Address - Street 2:
Mailing Address - City:BRISBANE
Mailing Address - State:CA
Mailing Address - Zip Code:94005-0162
Mailing Address - Country:US
Mailing Address - Phone:628-800-4217
Mailing Address - Fax:
Practice Address - Street 1:9811 WHITMAN AVE SW APT 20
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-1723
Practice Address - Country:US
Practice Address - Phone:628-800-4217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-16
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60580649363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health