Provider Demographics
NPI:1376746909
Name:KELLY, DEBRA (RTR)
Entity Type:Individual
Prefix:MS
First Name:DEBRA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:RTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 463
Mailing Address - Street 2:
Mailing Address - City:CARLISLE
Mailing Address - State:PA
Mailing Address - Zip Code:17013-0463
Mailing Address - Country:US
Mailing Address - Phone:443-280-2330
Mailing Address - Fax:
Practice Address - Street 1:665 WINTER ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3919
Practice Address - Country:US
Practice Address - Phone:503-561-5707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR00048082471C3402X
OR183282471C3402X
NMRRT 34862471C3402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography