Provider Demographics
NPI:1912575283
Name:BUSHONG, KELSEY LEIGH
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:LEIGH
Last Name:BUSHONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2628 SE 47TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-1504
Mailing Address - Country:US
Mailing Address - Phone:503-964-8112
Mailing Address - Fax:
Practice Address - Street 1:2628 SE 47TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-1504
Practice Address - Country:US
Practice Address - Phone:503-964-8112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X
OR374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No133N00000XDietary & Nutritional Service ProvidersNutritionist