Provider Demographics
NPI:1609893395
Name:O'BRIEN, KELLY RENEE (DNP)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:RENEE
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:RENEE
Other - Last Name:MACHUCA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DNP
Mailing Address - Street 1:913 NW GARDEN VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471
Mailing Address - Country:US
Mailing Address - Phone:541-440-1000
Mailing Address - Fax:541-440-1230
Practice Address - Street 1:913 NW GARDEN VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471
Practice Address - Country:US
Practice Address - Phone:541-440-1000
Practice Address - Fax:541-440-1230
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200450145NP363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR93-1148588OtherEMPLOYER IDENTIFICATION