Provider Demographics
NPI:1366157380
Name:KELLY, KERENSA ALEXANDRA (CNA)
Entity type:Individual
Prefix:
First Name:KERENSA
Middle Name:ALEXANDRA
Last Name:KELLY
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-3231
Mailing Address - Country:US
Mailing Address - Phone:509-607-7063
Mailing Address - Fax:
Practice Address - Street 1:1605 SE MEADOWBROOK BLVD STE 5
Practice Address - Street 2:
Practice Address - City:COLLEGE PLACE
Practice Address - State:WA
Practice Address - Zip Code:99324-1725
Practice Address - Country:US
Practice Address - Phone:509-591-0445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-16
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide