Provider Demographics
NPI:1912466467
Name:HAYZLETT, KELLY ANN (PA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:HAYZLETT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3240 FORT RD, TOPPENISH, WA 98948
Mailing Address - Street 2:HERITAGE UNIVERSITY PHYSICIAN ASSISTANT PROGRAM
Mailing Address - City:TOPPENISH
Mailing Address - State:WA
Mailing Address - Zip Code:98948
Mailing Address - Country:US
Mailing Address - Phone:509-865-0707
Mailing Address - Fax:
Practice Address - Street 1:1545 OSCEOLA ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80204-1445
Practice Address - Country:US
Practice Address - Phone:303-994-2821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-14
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program