1710248851 NPI number — KELSEY ALICE FISHER MSM, LDM, CPM

Table of content: KELSEY ALICE FISHER MSM, LDM, CPM (NPI 1710248851)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710248851 NPI number — KELSEY ALICE FISHER MSM, LDM, CPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FISHER
Provider First Name:
KELSEY
Provider Middle Name:
ALICE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSM, LDM, CPM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HANRAHAN
Provider Other First Name:
KELSEY
Provider Other Middle Name:
ALICE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1710248851
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5557 NE GOING ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97218-2630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
971-808-2864
Provider Business Mailing Address Fax Number:
971-999-7000

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5557 NE GOING ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97218-2630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
971-808-2864
Provider Business Practice Location Address Fax Number:
971-999-7000
Provider Enumeration Date:
06/05/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 176B00000X , with the licence number:  DEM-LD-10165673 , 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)





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