Healthcare Provider Details

I. General information

NPI: 1821233214
Provider Name (Legal Business Name): KELSIE JANELLE STORM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELSIE JANELLE BICKLEY M.D.

II. Dates (important events)

Enumeration Date: 12/13/2008
Last Update Date: 01/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3181 SW SAM JACKSON PARK RD MAIL CODE DC9R
PORTLAND OR
97239-3011
US

IV. Provider business mailing address

94 SE 73RD AVE
PORTLAND OR
97215-1437
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-9000
  • Fax:
Mailing address:
  • Phone: 360-601-7326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberLL17856
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: