Provider Demographics
NPI:1942714571
Name:CHANDLER, KELLY C (ARNP)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:C
Last Name:CHANDLER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:CHANDLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APN
Mailing Address - Street 1:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-861-8551
Practice Address - Street 1:550 17TH AVE FL 6
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-5788
Practice Address - Country:US
Practice Address - Phone:206-861-8550
Practice Address - Fax:206-861-8551
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-17
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60291128163W00000X
WAAP61004254363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1720371669OtherGROUP PRACTICE NPI
ILDS2377OtherRRMC GROUP PTAN
WA1942714571Medicaid