Provider Demographics
NPI:1366418535
Name:O'BRIEN, KERRY LEE (NP)
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:LEE
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4560 SE INTERNATIONAL WAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-4628
Mailing Address - Country:US
Mailing Address - Phone:503-312-4607
Mailing Address - Fax:503-296-2408
Practice Address - Street 1:4560 SE INTERNATIONAL WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-4628
Practice Address - Country:US
Practice Address - Phone:503-312-4607
Practice Address - Fax:503-296-2408
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200250084NP363LA2200X
OR200250083NP363LG0600X
OR200950006NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR000677Medicaid
WA1366418535Medicaid
OR000677Medicaid
WA1366418535Medicaid