Healthcare Provider Details

I. General information

NPI: 1447130471
Provider Name (Legal Business Name): NICOLE C KELLY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NIKKI KELLY

II. Dates (important events)

Enumeration Date: 09/02/2025
Last Update Date: 09/02/2025
Certification Date: 09/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1470 NW 4TH ST
REDMOND OR
97756-1366
US

IV. Provider business mailing address

1470 NW 4TH ST
REDMOND OR
97756-1366
US

V. Phone/Fax

Practice location:
  • Phone: 541-316-7520
  • Fax: 541-504-5505
Mailing address:
  • Phone: 541-316-7520
  • Fax: 541-504-5505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: