Basic Information
| Provider Information | |||||||||
| NPI: | 1306034277 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUARTE | ||||||||
| FirstName: | KELLIE | ||||||||
| MiddleName: | LEECLAIRE | ||||||||
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| Credential: | M.ED, PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8514 W GAGE BLVD | ||||||||
| Address2: | SUITE G | ||||||||
| City: | KENNEWICK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993368108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092221275 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8656 W GAGE BLVD STE 301B | ||||||||
| Address2: | |||||||||
| City: | KENNEWICK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993367145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092221275 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2007 | ||||||||
| LastUpdateDate: | 12/06/2017 | ||||||||
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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 | 101Y00000X | RC00054737 | WA | N | Behavioral Health & Social Service Providers | Counselor | 390200000X | 1306034277 | WA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363A00000X | PA60610771 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.