Provider Demographics
NPI:1144984154
Name:DEWEESE, KELLY (RN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:DEWEESE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 E WAY TO TIPPERARY ST
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-7526
Mailing Address - Country:US
Mailing Address - Phone:360-350-8351
Mailing Address - Fax:
Practice Address - Street 1:205 LILLY RD NE STE B
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5070
Practice Address - Country:US
Practice Address - Phone:360-489-1558
Practice Address - Fax:360-688-1066
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-26
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60283693163WP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0000XNursing Service ProvidersRegistered NursePain Management