Healthcare Provider Details

I. General information

NPI: 1336591197
Provider Name (Legal Business Name): KELLY IRENE WELLS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2016
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9427 SW BARNES RD STE 296
PORTLAND OR
97225-6667
US

IV. Provider business mailing address

541 NE 20TH AVE STE 225
PORTLAND OR
97232-2895
US

V. Phone/Fax

Practice location:
  • Phone: 503-297-3778
  • Fax: 503-297-7853
Mailing address:
  • Phone: 503-963-2801
  • Fax: 503-963-2825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201604735NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: