Provider Demographics
NPI:1356795504
Name:KELLY, KARY ANNE (NP-PP)
Entity type:Individual
Prefix:
First Name:KARY
Middle Name:ANNE
Last Name:KELLY
Suffix:
Gender:F
Credentials:NP-PP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3860 CRATER LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-9741
Mailing Address - Country:US
Mailing Address - Phone:541-858-1003
Mailing Address - Fax:541-857-4499
Practice Address - Street 1:3860 CRATER LAKE AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-9741
Practice Address - Country:US
Practice Address - Phone:541-858-1003
Practice Address - Fax:541-857-4499
Is Sole Proprietor?:No
Enumeration Date:2016-04-13
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201701664NP-PP363LF0000X
WY29710.1511363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500724440Medicaid