1043505308 NPI number — MS. KELLI ROBYN REILLY LMP, CHP

Table of content: MS. KELLI ROBYN REILLY LMP, CHP (NPI 1043505308)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043505308 NPI number — MS. KELLI ROBYN REILLY LMP, CHP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REILLY
Provider First Name:
KELLI
Provider Middle Name:
ROBYN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LMP, CHP
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:
1043505308
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1229 CORNWALL AVE
Provider Second Line Business Mailing Address:
SUITE 314
Provider Business Mailing Address City Name:
BELLINGHAM
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98225-5023
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-647-9187
Provider Business Mailing Address Fax Number:
360-714-6119

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1229 CORNWALL AVE
Provider Second Line Business Practice Location Address:
SUITE 314
Provider Business Practice Location Address City Name:
BELLINGHAM
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98225-5023
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-647-9187
Provider Business Practice Location Address Fax Number:
360-714-6119
Provider Enumeration Date:
06/15/2011

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: 174400000X , with the licence number:  MA00004798 , 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)





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