Provider Demographics
NPI:1073143806
Name:KINGSLEY, BRETT ALLAN (ND)
Entity Type:Individual
Prefix:DR
First Name:BRETT
Middle Name:ALLAN
Last Name:KINGSLEY
Suffix:
Gender:M
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 SE FLAVEL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-6034
Mailing Address - Country:US
Mailing Address - Phone:586-907-0031
Mailing Address - Fax:
Practice Address - Street 1:1630 SE FLAVEL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-6034
Practice Address - Country:US
Practice Address - Phone:586-907-0031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-21
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4289175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath