Provider Demographics
NPI:1699344671
Name:KELLY, KRISTEN MARIE (ND)
Entity type:Individual
Prefix:DR
First Name:KRISTEN
Middle Name:MARIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4920 S LANDING DR UNIT 304
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-5985
Mailing Address - Country:US
Mailing Address - Phone:248-802-0485
Mailing Address - Fax:
Practice Address - Street 1:3025 S CORBETT AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-4858
Practice Address - Country:US
Practice Address - Phone:503-552-1551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-23
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4400175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath