Provider Demographics
NPI:1306034277
Name:DUARTE, KELLIE LEECLAIRE (MED, PA-C)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:LEECLAIRE
Last Name:DUARTE
Suffix:
Gender:F
Credentials:MED, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8514 W GAGE BLVD
Mailing Address - Street 2:SUITE G
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-8108
Mailing Address - Country:US
Mailing Address - Phone:509-222-1275
Mailing Address - Fax:
Practice Address - Street 1:8656 W GAGE BLVD STE 301B
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-7145
Practice Address - Country:US
Practice Address - Phone:509-222-1275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-04
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00054737101Y00000X
WA1306034277390200000X
WAPA60610771363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program