Provider Demographics
NPI:1861589681
Name:JOHNSON, NANCY KELLY (MD)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:KELLY
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NANCY
Other - Middle Name:NORWOOD
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11790 SW BARNES RD STE 140
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5938
Mailing Address - Country:US
Mailing Address - Phone:503-643-2100
Mailing Address - Fax:503-643-7459
Practice Address - Street 1:11790 SW BARNES RD STE 140
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5938
Practice Address - Country:US
Practice Address - Phone:503-646-0161
Practice Address - Fax:503-643-7459
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD17293208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR058474Medicaid
F73756Medicare UPIN
OR058474Medicaid