Provider Demographics
NPI:1912631763
Name:EVINS, KELSEY JOAN (ATC)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:JOAN
Last Name:EVINS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:JOAN
Other - Last Name:JOHNSTON, GORBETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:1116 OFARRELL LN NW
Mailing Address - Street 2:
Mailing Address - City:ORTING
Mailing Address - State:WA
Mailing Address - Zip Code:98360-7418
Mailing Address - Country:US
Mailing Address - Phone:541-379-1825
Mailing Address - Fax:
Practice Address - Street 1:121 N DIVISION ST STE 310
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98001-4931
Practice Address - Country:US
Practice Address - Phone:253-545-5978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-15
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAA1609698332255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
73575OtherNATA
WAA160969833OtherSTATE OF WASHINGTON LICENSE
2000028155OtherCERTIFICATION NUMBER-BOC