Provider Demographics
NPI:1316524671
Name:MENNE, KELLY LYNN
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:LYNN
Last Name:MENNE
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 1:18700 SW GRAUER RD
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:OR
Mailing Address - Zip Code:97378-9767
Mailing Address - Country:US
Mailing Address - Phone:971-237-0841
Mailing Address - Fax:
Practice Address - Street 1:18700 SW GRAUER RD
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:OR
Practice Address - Zip Code:97378-9767
Practice Address - Country:US
Practice Address - Phone:971-237-0841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-24
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN