Healthcare Provider Details

I. General information

NPI: 1295819076
Provider Name (Legal Business Name): PATRICIA MARY KELLY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 08/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1270 KOTNUM ROAD
WARM SPRINGS OR
97761
US

IV. Provider business mailing address

1270 KOTNUM ROAD
WARM SPRINGS OR
97761
US

V. Phone/Fax

Practice location:
  • Phone: 541-553-1196
  • Fax:
Mailing address:
  • Phone: 541-553-1196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License NumberRN00074801
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: