MEDICARE: MS. KELLY RENEE CONKLIN DNP

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	363LF0000X	Family Nurse Practitioner	200450145NP	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	93-1148588	OTHER	OR	EMPLOYER IDENTIFICATION

General Provider Information

NPI Number	:	1609893395
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KELLY RENEE CONKLIN DNP

Provider Business Mailing Address
First Line	:	913 NW GARDEN VALLEY BLVD
Second Line	:
City	:	ROSEBURG
State	:	OR
Zip	:	97471
Country	:	US
Telephone Number	:	541-440-1000
Fax Number	:	541-440-1230

Provider Business Practice Location Address
First Line	:	913 NW GARDEN VALLEY BLVD
Second Line	:
City	:	ROSEBURG
State	:	OR
Zip	:	97471
Country	:	US
Telephone Number	:	541-440-1000
Fax Number	:	541-440-1230

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

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	02/25/2026

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