MEDICARE: KELLY C YAN PMHNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	202006258NP-PP	OR
2	163W00000X	Registered Nurse	201809234RN	OR

General Provider Information

NPI Number	:	1255965166
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY C YAN PMHNP-BC

Provider Business Mailing Address
First Line	:	1020 SW TAYLOR ST. SUITE 448
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97205-2509
Country	:	US
Telephone Number	:	971-300-4254
Fax Number	:

Provider Business Practice Location Address
First Line	:	1020 SW TAYLOR ST. SUITE 448
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97205-2509
Country	:	US
Telephone Number	:	971-300-4254
Fax Number	:	503-200-1241

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/29/2020
Last Update Date	:	06/18/2025

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