Provider Demographics
NPI:1366812380
Name:WITBECK, KELLY (DNP, ARNP)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:WITBECK
Suffix:
Gender:F
Credentials:DNP, ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 SW 11TH AVE STE 915
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2123
Mailing Address - Country:US
Mailing Address - Phone:971-366-2315
Mailing Address - Fax:
Practice Address - Street 1:833 SW 11TH AVE STE 915
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2123
Practice Address - Country:US
Practice Address - Phone:971-366-2315
Practice Address - Fax:360-245-9181
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-02
Last Update Date:2024-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201507845NP-PP363LF0000X, 363LP0808X
WAAP60787605363LF0000X, 363LP0808X
FL9277250363LF0000X, 363LP0808X
MTNUR-APRN-LIC-170570363LF0000X, 363LP0808X
AK167743363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily