Provider Demographics
NPI:1932853520
Name:PARKS, KELLIE R (RN)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:R
Last Name:PARKS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:RAHUNN
Other - Last Name:MERCER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2507 BITAR AVE APT C
Mailing Address - Street 2:
Mailing Address - City:JOINT BASE LEWIS MCCHORD
Mailing Address - State:WA
Mailing Address - Zip Code:98433-1810
Mailing Address - Country:US
Mailing Address - Phone:951-440-1750
Mailing Address - Fax:
Practice Address - Street 1:6700 MARTIN WAY E STE 117
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98516-5586
Practice Address - Country:US
Practice Address - Phone:360-413-6910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-11
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61177840163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse