Provider Demographics
NPI:1659083129
Name:GRANT, KELLY ROSE (WHCNP, CNM)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ROSE
Last Name:GRANT
Suffix:
Gender:F
Credentials:WHCNP, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19365 SW 65TH AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-9196
Mailing Address - Country:US
Mailing Address - Phone:503-454-0018
Mailing Address - Fax:503-848-3471
Practice Address - Street 1:22400 SALAMO RD STE 201
Practice Address - Street 2:
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068-8269
Practice Address - Country:US
Practice Address - Phone:503-723-7234
Practice Address - Fax:503-650-4464
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-15
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10005243367A00000X
OR10002453363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty