Provider Demographics
NPI:1104937093
Name:KELLEY, MARA WELLS (MD)
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:WELLS
Last Name:KELLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARA
Other - Middle Name:WELLS
Other - Last Name:VOLKOMMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 5096
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98227-5096
Mailing Address - Country:US
Mailing Address - Phone:360-738-2200
Mailing Address - Fax:360-752-5678
Practice Address - Street 1:4545 CORDATA PKWY
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-7123
Practice Address - Country:US
Practice Address - Phone:360-738-2200
Practice Address - Fax:360-752-5678
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAML20008684208000000X
WAMD60170884208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1104937093Medicaid
WA0212KEOtherREGENCE
WA0265880OtherL&I AND CRIME VICTIMS
WA0212KEOtherREGENCE