Basic Information
| Provider Information | |||||||||
| NPI: | 1104937093 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLEY | ||||||||
| FirstName: | MARA | ||||||||
| MiddleName: | WELLS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VOLKOMMER | ||||||||
| OtherFirstName: | MARA | ||||||||
| OtherMiddleName: | WELLS | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 5096 | ||||||||
| Address2: | |||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982275096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607382200 | ||||||||
| FaxNumber: | 3607525678 | ||||||||
| Practice Location | |||||||||
| Address1: | 4545 CORDATA PKWY | ||||||||
| Address2: | |||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982267123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607382200 | ||||||||
| FaxNumber: | 3607525678 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 11/19/2010 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ML20008684 | WA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | MD60170884 | WA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1104937093 | 05 | WA | MEDICAID | 0212KE | 01 | WA | REGENCE | OTHER | 0265880 | 01 | WA | L&I AND CRIME VICTIMS | OTHER |