Provider Demographics
NPI:1801570031
Name:ROSILLO, KELLIN (PSS)
Entity type:Individual
Prefix:
First Name:KELLIN
Middle Name:
Last Name:ROSILLO
Suffix:
Gender:F
Credentials:PSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 ECOLS ST N APT 4
Mailing Address - Street 2:
Mailing Address - City:MONMOUTH
Mailing Address - State:OR
Mailing Address - Zip Code:97361-1403
Mailing Address - Country:US
Mailing Address - Phone:435-294-9529
Mailing Address - Fax:
Practice Address - Street 1:945 SE UGLOW AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-2642
Practice Address - Country:US
Practice Address - Phone:503-837-1762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-08
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000108994175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist