Provider Demographics
NPI:1487933610
Name:PADGETT, KELLY MICHELE (OD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:MICHELE
Last Name:PADGETT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 COOKS HILL RD
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-9072
Mailing Address - Country:US
Mailing Address - Phone:360-736-4447
Mailing Address - Fax:360-807-0324
Practice Address - Street 1:1805 COOKS HILL RD
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-9072
Practice Address - Country:US
Practice Address - Phone:360-736-4447
Practice Address - Fax:360-807-0324
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-05
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60236154152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2015400Medicaid