Healthcare Provider Details

I. General information

NPI: 1932577400
Provider Name (Legal Business Name): KELLY RICKMAN CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2015
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 BELTLINE RD
SPRINGFIELD OR
97477-1091
US

IV. Provider business mailing address

890 BELTLINE RD
SPRINGFIELD OR
97477-1091
US

V. Phone/Fax

Practice location:
  • Phone: 541-654-9076
  • Fax: 855-525-4525
Mailing address:
  • Phone: 541-515-6556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberAP60593727
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number201704023NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: