Provider Demographics
NPI:1114398690
Name:ADAMS, KELLYN
Entity Type:Individual
Prefix:
First Name:KELLYN
Middle Name:
Last Name:ADAMS
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 1:2330 NW FLANDERS ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210
Mailing Address - Country:US
Mailing Address - Phone:503-701-8766
Mailing Address - Fax:503-241-5484
Practice Address - Street 1:2330 NW FLANDERS ST
Practice Address - Street 2:SUITE 101
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210
Practice Address - Country:US
Practice Address - Phone:503-701-8766
Practice Address - Fax:503-241-5484
Is Sole Proprietor?:No
Enumeration Date:2015-10-09
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3024175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath