Provider Demographics
NPI:1457605958
Name:WASHBURN, KELLY (MSN, NP-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WASHBURN
Suffix:
Gender:F
Credentials:MSN, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5935 SE BELMONT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-1925
Mailing Address - Country:US
Mailing Address - Phone:971-328-0083
Mailing Address - Fax:833-502-1522
Practice Address - Street 1:5935 SE BELMONT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-1925
Practice Address - Country:US
Practice Address - Phone:860-670-6348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-05
Last Update Date:2021-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5118363L00000X
OR201503413NP-PP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner