Basic Information
| Provider Information | |||||||||
| NPI: | 1972836658 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLOW | ||||||||
| FirstName: | NOLAN | ||||||||
| MiddleName: | WESLEY | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9315 GRAVELLY LAKE DR SW | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984991574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535815200 | ||||||||
| FaxNumber: | 2535815203 | ||||||||
| Practice Location | |||||||||
| Address1: | 144 169TH ST S | ||||||||
| Address2: | SUITE B | ||||||||
| City: | SPANAWAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983878201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538468918 | ||||||||
| FaxNumber: | 2538468126 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2009 | ||||||||
| LastUpdateDate: | 11/24/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT60100044 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0048KE | 01 | WA | REGENCE BLUE SHIELD | OTHER | 0253931 | 01 | WA | LABOR AND INDUSTRIES | OTHER |