Healthcare Provider Details

I. General information

NPI: 1356183131
Provider Name (Legal Business Name): MARICELA KELLY RNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2024
Last Update Date: 06/11/2024
Certification Date: 06/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 NW 11TH ST MEDICAL STAFF SERVICES
HERMISTON OR
97838
US

IV. Provider business mailing address

610 NW 11TH ST MEDICAL STAFF SERVICES
HERMISTON OR
97838
US

V. Phone/Fax

Practice location:
  • Phone: 541-667-3403
  • Fax:
Mailing address:
  • Phone: 541-667-3403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number201605956RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: