Provider Demographics
NPI:1245420074
Name:DALE, KELLY A (NP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:DALE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 4749
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-0227
Mailing Address - Country:US
Mailing Address - Phone:541-789-5516
Mailing Address - Fax:541-789-5518
Practice Address - Street 1:2825 E BARNETT RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8332
Practice Address - Country:US
Practice Address - Phone:541-789-7000
Practice Address - Fax:503-220-3929
Is Sole Proprietor?:No
Enumeration Date:2007-07-27
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CARN665150363LF0000X
OR200850060363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily