Provider Demographics
NPI:1053402693
Name:REIS, KELLEY RENEE (ND)
Entity type:Individual
Prefix:DR
First Name:KELLEY
Middle Name:RENEE
Last Name:REIS
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:172 SE 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-4129
Mailing Address - Country:US
Mailing Address - Phone:503-693-0904
Mailing Address - Fax:503-693-0994
Practice Address - Street 1:172 SE 6TH AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4129
Practice Address - Country:US
Practice Address - Phone:503-693-0904
Practice Address - Fax:503-693-0994
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1388175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR022973Medicaid