Provider Demographics
NPI:1669670550
Name:BALTAZAR, KELLY MARY (ND, DC)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:MARY
Last Name:BALTAZAR
Suffix:
Gender:F
Credentials:ND, DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7425 SW ALOMA WAY APT 1
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-7919
Mailing Address - Country:US
Mailing Address - Phone:425-269-8187
Mailing Address - Fax:
Practice Address - Street 1:3025 SW CORBETT AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-4858
Practice Address - Country:US
Practice Address - Phone:503-552-1551
Practice Address - Fax:503-226-8133
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5843111N00000X
OR4063175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No111N00000XChiropractic ProvidersChiropractor