Healthcare Provider Details

I. General information

NPI: 1639930779
Provider Name (Legal Business Name): DAVID ALLEN KELLY JR. CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2024
Last Update Date: 05/07/2024
Certification Date: 05/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3303 S BOND AVE
PORTLAND OR
97239-4501
US

IV. Provider business mailing address

1400 SW 5TH AVE STE 500
PORTLAND OR
97201-5537
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-6346
  • Fax: 503-494-5385
Mailing address:
  • Phone: 866-617-6855
  • Fax: 503-346-8015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number202207583NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: