Provider Demographics
NPI:1639930779
Name:KELLY, DAVID ALLEN JR (CRNP)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:ALLEN
Last Name:KELLY
Suffix:JR
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1400 SW 5TH AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-5537
Mailing Address - Country:US
Mailing Address - Phone:866-617-6855
Mailing Address - Fax:503-346-8015
Practice Address - Street 1:3303 S BOND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4501
Practice Address - Country:US
Practice Address - Phone:503-494-6346
Practice Address - Fax:503-494-5385
Is Sole Proprietor?:No
Enumeration Date:2024-01-16
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OR202207583NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily