Provider Demographics
NPI:1487706115
Name:KELLY-HEDRICK, HEATHER M (MD)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:M
Last Name:KELLY-HEDRICK
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:PO BOX 34584
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1584
Mailing Address - Country:US
Mailing Address - Phone:509-241-7349
Mailing Address - Fax:509-241-7628
Practice Address - Street 1:2700 152ND AVE NE
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-5543
Practice Address - Country:US
Practice Address - Phone:425-883-5151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00031077208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8157943Medicaid
WAG8809117Medicare PIN
WAG8809125Medicare PIN
WAF87451Medicare UPIN
WAG8809123Medicare PIN
WAGAB04441Medicare PIN
WAG8809121Medicare PIN
WA8157943Medicaid
WAG8872402Medicare PIN