Individual
KELLY MARIE LANDLE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
P.A.-C
Contact information
Practice address
606 E MAIN ST, KENDRICK, ID 83537
(208) 289-3841
(208) 289-3961
Mailing address
700 S MAIN ST, MOSCOW, ID 83843-3046
(208) 882-4511
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA-345
ID
363AM0700X
Medical Physician Assistant
PA10004069
WA
363AS0400X
Surgical Physician Assistant
PA10004069
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0141613
STATE WORK COMP
WA
05
—
806673600
—
ID
05
—
8201634
—
WA
01
—
970027265
RAILROAD MEDICARE
—
Enumeration date
03/08/2006
Last updated
04/16/2019
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