1417943630 NPI number — KELLY A TIMMONS M.D. PHD

Table of content: KELLY A TIMMONS M.D. PHD (NPI 1417943630)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417943630 NPI number — KELLY A TIMMONS M.D. PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TIMMONS
Provider First Name:
KELLY
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D. PHD
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:
1417943630
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3800 SUMMITVIEW AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YAKIMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98902-2715
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-574-6000
Provider Business Mailing Address Fax Number:
509-225-2714

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1470 N 16TH AVE
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
YAKIMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98902-1381
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-574-6000
Provider Business Practice Location Address Fax Number:
509-225-2714
Provider Enumeration Date:
09/22/2005

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: 207RR0500X , with the licence number:  M10053 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00715305B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 807841500 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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