Provider Demographics
NPI:1952854481
Name:KARA KELLY, LLC
Entity Type:Organization
Organization Name:KARA KELLY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KARA
Authorized Official - Middle Name:L
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:949-274-2881
Mailing Address - Street 1:2955 N HWY 97
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-7559
Mailing Address - Country:US
Mailing Address - Phone:949-274-2881
Mailing Address - Fax:
Practice Address - Street 1:2955 N HWY 97
Practice Address - Street 2:SUITE 102
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-7559
Practice Address - Country:US
Practice Address - Phone:949-274-2881
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-02
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201604186NP-PP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty