Provider Demographics
NPI:1568691756
Name:KELLEY, KATHLEEN (PMHNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15110 BOONES FERRY RD STE 248
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-3498
Mailing Address - Country:US
Mailing Address - Phone:503-830-3215
Mailing Address - Fax:503-699-4133
Practice Address - Street 1:15110 BOONES FERRY RD STE 248
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-3498
Practice Address - Country:US
Practice Address - Phone:503-830-3215
Practice Address - Fax:503-699-4133
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-08
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200950083NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health