Provider Demographics
NPI:1881304400
Name:WASHINGTON, KELLY SUSAN
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:SUSAN
Last Name:WASHINGTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 MORGANTOWN AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-4335
Mailing Address - Country:US
Mailing Address - Phone:304-366-5832
Mailing Address - Fax:
Practice Address - Street 1:909 MORGANTOWN AVE
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-4335
Practice Address - Country:US
Practice Address - Phone:304-366-5832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator