Provider Demographics
NPI:1700412319
Name:EBRAHIMI, KELLY BLAKE (DO)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:BLAKE
Last Name:EBRAHIMI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:BLAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1 JARRETT WHITE RD
Mailing Address - Street 2:
Mailing Address - City:TRIPLER ARMY MEDICAL CENTER
Mailing Address - State:HI
Mailing Address - Zip Code:96859-5001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9040 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-5001
Practice Address - Country:US
Practice Address - Phone:253-968-2252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-14
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDOS-22922084P0800X, 208D00000X
390200000X
WAOP615756512084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program