Provider Demographics
NPI:1093581811
Name:OHERN, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:OHERN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 3RD AVE N
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IA
Mailing Address - Zip Code:52732-3948
Mailing Address - Country:US
Mailing Address - Phone:156-332-1547
Mailing Address - Fax:
Practice Address - Street 1:3725 PROVIDENCE POINT DR SE
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98029-7219
Practice Address - Country:US
Practice Address - Phone:425-391-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-01
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAP62058164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse