Basic Information
| Provider Information | |||||||||
| NPI: | 1730543844 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENDERSHOT | ||||||||
| FirstName: | KELLY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2522 106TH PL SE | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982084463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253507507 | ||||||||
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| Practice Location | |||||||||
| Address1: | 925 SENECA ST | ||||||||
| Address2: | MS: H8-GME | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981012742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065155811 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2016 | ||||||||
| LastUpdateDate: | 04/05/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.