Provider Demographics
NPI:1871307843
Name:KELLEY, EILEEN APRIL
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:APRIL
Last Name:KELLEY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3008 S OLYMPIA ST
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99337-4360
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1515 E COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:OTHELLO
Practice Address - State:WA
Practice Address - Zip Code:99344-1846
Practice Address - Country:US
Practice Address - Phone:509-488-5256
Practice Address - Fax:509-488-9939
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-01
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH60886628124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist