Provider Demographics
NPI:1689966459
Name:KELLY, CAROLINE LANSING (MD)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:LANSING
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1075 GRANDVIEW AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-5118
Mailing Address - Country:US
Mailing Address - Phone:541-479-8363
Mailing Address - Fax:541-476-2841
Practice Address - Street 1:1075 GRANDVIEW AVE STE 200
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5118
Practice Address - Country:US
Practice Address - Phone:541-479-8363
Practice Address - Fax:541-476-2841
Is Sole Proprietor?:No
Enumeration Date:2011-05-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD172322207V00000X
PAMT199290207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORMD172322OtherOREGON MEDICAL LICENSE
ORMD172322OtherOREGON MEDICAL LICENSE