Provider Demographics
NPI:1902198708
Name:BLY, KC (CNM)
Entity type:Individual
Prefix:
First Name:KC
Middle Name:
Last Name:BLY
Suffix:
Gender:M
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13898 NE 28TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-8844
Mailing Address - Country:US
Mailing Address - Phone:360-541-2421
Mailing Address - Fax:
Practice Address - Street 1:2525 NE 139TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-2719
Practice Address - Country:US
Practice Address - Phone:360-882-2778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-11
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61053772367A00000X
OR202107304NP-PP367A00000X, 367A00000X
CT000352367A00000X
UT11347841-4405367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT009003526Medicaid
OR500795806Medicaid
CTD400048741 - C00023Medicare PIN