Provider Demographics
NPI:1144191628
Name:PORTER, KELLY ANNE
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:PORTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 N 85TH ST APT C339
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-3789
Mailing Address - Country:US
Mailing Address - Phone:206-558-4488
Mailing Address - Fax:206-691-8281
Practice Address - Street 1:12221 VILLAGE CENTER PL STE 203
Practice Address - Street 2:
Practice Address - City:MUKILTEO
Practice Address - State:WA
Practice Address - Zip Code:98275-6080
Practice Address - Country:US
Practice Address - Phone:206-558-4488
Practice Address - Fax:206-691-8281
Is Sole Proprietor?:No
Enumeration Date:2025-09-16
Last Update Date:2025-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program