Provider Demographics
NPI:1790295889
Name:HEAD, KELLY (ND)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:HEAD
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 SW 10TH AVE STE 801
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2709
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:511 SW 10TH AVE STE 801
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2709
Practice Address - Country:US
Practice Address - Phone:503-230-8973
Practice Address - Fax:503-230-8978
Is Sole Proprietor?:No
Enumeration Date:2017-10-03
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath