Basic Information
| Provider Information | |||||||||
| NPI: | 1861452534 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUPPLE | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD, MPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 E KINCAID ST | ||||||||
| Address2: | ATTN: CREDENTIALING | ||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982744127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604282500 | ||||||||
| FaxNumber: | 3604286485 | ||||||||
| Practice Location | |||||||||
| Address1: | 3823 - 172ND STREET NE | ||||||||
| Address2: | CASCADE SKAGIT HEALTH ALLIANCE | ||||||||
| City: | ARLINGTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606578700 | ||||||||
| FaxNumber: | 3606578717 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2006 | ||||||||
| LastUpdateDate: | 09/27/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083X0100X | 015816 | ME | N | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine | 207P00000X | 102269 | MN | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 2083X0100X | MD60364670 | WA | Y | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1861452534 | 05 | WA | MEDICAID |