Provider Demographics
NPI:1104307867
Name:STANG, KELSEY
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:STANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15452 SE BUSH ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-2249
Mailing Address - Country:US
Mailing Address - Phone:503-724-7028
Mailing Address - Fax:
Practice Address - Street 1:2406 SE 60TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-1303
Practice Address - Country:US
Practice Address - Phone:503-457-7799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4167175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath