Provider Demographics
NPI:1255637237
Name:MARTYN, KELLEN TAVERNITI (CRNA)
Entity type:Individual
Prefix:MR
First Name:KELLEN
Middle Name:TAVERNITI
Last Name:MARTYN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 SW CAMELOT CT APT 503
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-3754
Mailing Address - Country:US
Mailing Address - Phone:509-475-1524
Mailing Address - Fax:
Practice Address - Street 1:10180 SE SUNNYSIDE RD
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-8970
Practice Address - Country:US
Practice Address - Phone:503-652-2880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-08
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200541945RN163W00000X
OR201160010CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse