Healthcare Provider Details

I. General information

NPI: 1477852259
Provider Name (Legal Business Name): KELSEY LINDE RICHARDSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2011
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3181 SW SAM JACKSON HALL RD
PORTLAND OR
97239
US

IV. Provider business mailing address

3181 SW SAM JACKSON HALL RD
PORTLAND OR
97239
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-4265
  • Fax:
Mailing address:
  • Phone: 503-494-4265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberML60224535
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License NumberMD182992
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: