Provider Demographics
NPI:1740523158
Name:PROVENZANO, KACEY HELENA (MD)
Entity type:Individual
Prefix:
First Name:KACEY
Middle Name:HELENA
Last Name:PROVENZANO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:550 GAGE BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-9532
Mailing Address - Country:US
Mailing Address - Phone:509-942-3288
Mailing Address - Fax:509-942-3167
Practice Address - Street 1:780 SWIFT BLVD STE 201
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352
Practice Address - Country:US
Practice Address - Phone:509-942-3288
Practice Address - Fax:509-942-3167
Is Sole Proprietor?:No
Enumeration Date:2013-04-03
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA264720208800000X
WAMD60964556208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology