Provider Demographics
NPI:1578531646
Name:KELLY, JANICE J (ANP)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:J
Last Name:KELLY
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 NW 22ND AVE, STE 640
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2993
Mailing Address - Country:US
Mailing Address - Phone:503-229-7976
Mailing Address - Fax:503-274-4867
Practice Address - Street 1:1130 NW 22ND AVE, STE 640
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2993
Practice Address - Country:US
Practice Address - Phone:503-229-7976
Practice Address - Fax:503-274-4867
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAPRN-3153363L00000X
WAAP30002264363L00000X
OR000032737N3363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR268948Medicaid
ORP26842Medicare UPIN
ORR106811Medicare ID - Type Unspecified