Provider Demographics
NPI:1487638235
Name:BURNETT, KELLEY (DO)
Entity Type:Individual
Prefix:DR
First Name:KELLEY
Middle Name:
Last Name:BURNETT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 RAMSEY AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-5792
Mailing Address - Country:US
Mailing Address - Phone:541-955-5683
Mailing Address - Fax:541-955-0983
Practice Address - Street 1:700 RAMSEY AVE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5792
Practice Address - Country:US
Practice Address - Phone:541-955-5683
Practice Address - Fax:541-955-0983
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO19729208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR299499Medicaid
OR299499Medicaid
OR079322Medicare UPIN