Provider Demographics
NPI:1679760136
Name:COLELLO, KELLY R (LMP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:R
Last Name:COLELLO
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:R
Other - Last Name:WANAMAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:17651 1ST AVE. S.
Mailing Address - Street 2:STE. #101
Mailing Address - City:NORMANDY PARK
Mailing Address - State:WA
Mailing Address - Zip Code:98148
Mailing Address - Country:US
Mailing Address - Phone:206-241-3836
Mailing Address - Fax:206-241-3967
Practice Address - Street 1:17651 1ST AVE. S.
Practice Address - Street 2:STE. #101
Practice Address - City:NORMANDY PARK
Practice Address - State:WA
Practice Address - Zip Code:98148
Practice Address - Country:US
Practice Address - Phone:206-241-3836
Practice Address - Fax:206-241-3967
Is Sole Proprietor?:No
Enumeration Date:2007-09-28
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00019960225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0224172OtherLABOR AND INDUSTRIES