Basic Information
| Provider Information | |||||||||
| NPI: | 1295391357 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANN | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 939 CAROLINE ST | ||||||||
| Address2: | |||||||||
| City: | PORT ANGELES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983623997 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604177724 | ||||||||
| FaxNumber: | 3604525772 | ||||||||
| Practice Location | |||||||||
| Address1: | 939 CAROLINE ST | ||||||||
| Address2: | |||||||||
| City: | PORT ANGELES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983623997 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604177724 | ||||||||
| FaxNumber: | 3604525772 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2019 | ||||||||
| LastUpdateDate: | 09/30/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | AP60971043 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.