Provider Demographics
NPI:1902198708
Name:BLY, KC (CNM)
Entity Type:Individual
Prefix:
First Name:KC
Middle Name:
Last Name:BLY
Suffix:
Gender:M
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7650 SW BEVELAND RD STE 200
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8692
Mailing Address - Country:US
Mailing Address - Phone:503-601-3615
Mailing Address - Fax:503-646-1683
Practice Address - Street 1:1508 DIVISION ST STE 205
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-1585
Practice Address - Country:US
Practice Address - Phone:503-657-1071
Practice Address - Fax:503-657-3321
Is Sole Proprietor?:No
Enumeration Date:2011-05-11
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202107304NP-PP367A00000X, 367A00000X
CA1922176B00000X
CT000352367A00000X
UT11347841-4405367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT009003526Medicaid
OR500795806Medicaid
CTD400048741 - C00023Medicare PIN