Provider Demographics
NPI:1063707198
Name:RANDELL, KELLI (MD)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:RANDELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3475 N SARATOGA ST
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98278-4927
Mailing Address - Country:US
Mailing Address - Phone:360-257-9561
Mailing Address - Fax:
Practice Address - Street 1:3475 N SARATOGA ST
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98278
Practice Address - Country:US
Practice Address - Phone:360-257-9561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-16
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01071612A207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine