Provider Demographics
NPI:1568469765
Name:KELLEY, DENISE CHRISTINE (MD)
Entity Type:Individual
Prefix:DR
First Name:DENISE
Middle Name:CHRISTINE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:DENISE
Other - Middle Name:CHRISTINE
Other - Last Name:TUTTLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:100 MULLINS DR STE A1
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355-2868
Mailing Address - Country:US
Mailing Address - Phone:541-451-6920
Mailing Address - Fax:541-451-6924
Practice Address - Street 1:100 MULLINS DR STE A1
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-2868
Practice Address - Country:US
Practice Address - Phone:541-451-6920
Practice Address - Fax:541-451-6924
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD072853L207Q00000X
WY10112A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA050121Medicare ID - Type Unspecified
PAH45476Medicare UPIN