Provider Demographics
NPI:1811166093
Name:WOODARD, KELLY ANNE (SLP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:WOODARD
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12541 WEDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98233-3806
Mailing Address - Country:US
Mailing Address - Phone:360-770-5432
Mailing Address - Fax:
Practice Address - Street 1:300 S 18TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4661
Practice Address - Country:US
Practice Address - Phone:360-424-1320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-21
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00003149235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist