Provider Demographics
NPI:1821495888
Name:DRURY, KELLY A (MACOM, LAC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:DRURY
Suffix:
Gender:F
Credentials:MACOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4041 SE YAMHILL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-4444
Mailing Address - Country:US
Mailing Address - Phone:973-865-7109
Mailing Address - Fax:
Practice Address - Street 1:4041 SE YAMHILL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-4444
Practice Address - Country:US
Practice Address - Phone:973-865-7109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-19
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC170149171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist