Provider Demographics
NPI:1003560517
Name:KELLY WASHBURN, INC.
Entity Type:Organization
Organization Name:KELLY WASHBURN, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:PONDOLFINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:971-328-0083
Mailing Address - Street 1:5935 SE BELMONT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-1925
Mailing Address - Country:US
Mailing Address - Phone:541-638-0261
Mailing Address - Fax:833-520-1522
Practice Address - Street 1:5935 SE BELMONT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-1925
Practice Address - Country:US
Practice Address - Phone:541-638-0261
Practice Address - Fax:833-520-1522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-04
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500689145Medicaid