Provider Demographics
NPI:1104089309
Name:KELLY CLAYTON FNP INC
Entity type:Organization
Organization Name:KELLY CLAYTON FNP INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CLAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:541-878-3537
Mailing Address - Street 1:PO BOX 1
Mailing Address - Street 2:
Mailing Address - City:SHADY COVE
Mailing Address - State:OR
Mailing Address - Zip Code:97539-0001
Mailing Address - Country:US
Mailing Address - Phone:541-878-3537
Mailing Address - Fax:541-878-0990
Practice Address - Street 1:387 PINETOP TERRACE
Practice Address - Street 2:
Practice Address - City:SHADY COVE
Practice Address - State:OR
Practice Address - Zip Code:97539
Practice Address - Country:US
Practice Address - Phone:541-878-3537
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-08
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200150078NP261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1396744769OtherINDIVIDUAL NPI
OR228862Medicaid
OR228862Medicaid