Provider Demographics
NPI:1144419599
Name:HILDENBRAND, KELLY CLARK (BSN, RN)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:CLARK
Last Name:HILDENBRAND
Suffix:
Gender:F
Credentials:BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3925 SE 48TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-3231
Mailing Address - Country:US
Mailing Address - Phone:503-771-5602
Mailing Address - Fax:
Practice Address - Street 1:3925 SE 48TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-3231
Practice Address - Country:US
Practice Address - Phone:503-771-5602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-22
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OROSBN 09600231RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse