Provider Demographics
NPI:1245469600
Name:SIMMONS, KELLY MARIE (DC)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:MARIE
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 NW 12THE AVE
Mailing Address - Street 2:#1237
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-4151
Mailing Address - Country:US
Mailing Address - Phone:612-590-0055
Mailing Address - Fax:
Practice Address - Street 1:12400 PILLSBURY AVE S
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-3835
Practice Address - Country:US
Practice Address - Phone:612-590-0055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-07
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5061111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor