Provider Demographics
NPI:1396744769
Name:CLAYTON, KELLY M (FNP)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:M
Last Name:CLAYTON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 5870
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97415-0234
Mailing Address - Country:US
Mailing Address - Phone:541-469-7401
Mailing Address - Fax:541-469-7083
Practice Address - Street 1:446 OAK ST
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415-9612
Practice Address - Country:US
Practice Address - Phone:541-469-7401
Practice Address - Fax:541-469-7083
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200150078NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR228862Medicaid
OR228862Medicaid