Healthcare Provider Details

I. General information

NPI: 1689670226
Provider Name (Legal Business Name): LORI H KELLY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 08/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3303 SW BOND AVE
PORTLAND OR
97239-4501
US

IV. Provider business mailing address

3181 SW SAM JACKSON PARK RD GH 219
PORTLAND OR
97239-3011
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-4373
  • Fax:
Mailing address:
  • Phone: 503-494-1484
  • Fax: 503-494-1409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA00942
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: