Provider Demographics
NPI:1235970559
Name:THOMSEN, KELLI LYNN (LE)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:LYNN
Last Name:THOMSEN
Suffix:
Gender:F
Credentials:LE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3925 SW MULTNOMAH BLVD APT 103
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-3589
Mailing Address - Country:US
Mailing Address - Phone:503-890-5355
Mailing Address - Fax:
Practice Address - Street 1:917 NW OVERTON ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-3197
Practice Address - Country:US
Practice Address - Phone:503-890-5355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-03
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORCOS-FT-935744171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach