Healthcare Provider Details

I. General information

NPI: 1497590343
Provider Name (Legal Business Name): KAYLA ANN KELLY FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2024
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3031 NE STEPHENS ST
ROSEBURG OR
97470-6237
US

IV. Provider business mailing address

PO BOX 1700
ROSEBURG OR
97470-0414
US

V. Phone/Fax

Practice location:
  • Phone: 541-229-7038
  • Fax:
Mailing address:
  • Phone: 541-229-7038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10062231
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: