1700887338 NPI number — KELLY L EVANS M.D.

Table of content: DEBORAH ROSADO LMHC (NPI 1033726849)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700887338 NPI number — KELLY L EVANS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EVANS
Provider First Name:
KELLY
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700887338
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/22/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5096
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELLINGHAM
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98227-5096
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-738-2200
Provider Business Mailing Address Fax Number:
360-752-5686

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4545 CORDATA PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLINGHAM
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98226-7123
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-738-2200
Provider Business Practice Location Address Fax Number:
360-752-5686
Provider Enumeration Date:
08/04/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  36096988 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: MD60114770 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1700887338 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 036096988 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0031EV . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0261814 . This is a "L&I AND CRIME VICTIMS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 5827708 . This is a "AETNA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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