1104089309 NPI number — KELLY CLAYTON FNP INC

Table of content: (NPI 1104089309)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104089309 NPI number — KELLY CLAYTON FNP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KELLY CLAYTON FNP INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
HEALTH CARE BY HOUSE CALL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104089309
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHADY COVE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97539-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-878-3537
Provider Business Mailing Address Fax Number:
541-878-0990

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
387 PINETOP TERRACE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHADY COVE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97539
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-878-3537
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/08/2008

Additional Information

Authorized Official

Authorized Official Last Name:
CLAYTON
Authorized Official First Name:
KELLY
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
541-878-3537

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  200150078NP , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1396744769 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 228862 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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