Provider Demographics
NPI:1386220523
Name:DAVIS, KELLY (CHW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:CHW
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 546
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-0132
Mailing Address - Country:US
Mailing Address - Phone:541-782-8242
Mailing Address - Fax:
Practice Address - Street 1:54771 MCKENZIE HWY
Practice Address - Street 2:
Practice Address - City:BLUE RIVER
Practice Address - State:OR
Practice Address - Zip Code:97413-9790
Practice Address - Country:US
Practice Address - Phone:541-822-3341
Practice Address - Fax:541-822-3836
Is Sole Proprietor?:No
Enumeration Date:2021-03-18
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker