Provider Demographics
NPI:1255965166
Name:YAN, KELLY C (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:C
Last Name:YAN
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 SW TAYLOR ST. SUITE 448
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2509
Mailing Address - Country:US
Mailing Address - Phone:971-300-4254
Mailing Address - Fax:
Practice Address - Street 1:1020 SW TAYLOR ST. SUITE 448
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2509
Practice Address - Country:US
Practice Address - Phone:971-300-4254
Practice Address - Fax:503-200-1241
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-29
Last Update Date:2025-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202006258NP-PP363LP0808X
OR201809234RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse