Individual ProviderNicole KellyPhysician AssistantPhysician Assistants & Advanced Practice Nursing ProvidersPractice Address3181 SW Sam Jackson Park Rd, Portland, OR 97239-3011(503) 494-4314(866) 617-6855PECOS EnrollmentBased on the most recent information from CMS, provider Nicole Kelly is legally eligible to order and refer claims for Part B, HHA, DME and PMD services.Part BMedicare Part BEnrolledHHAHome Health AgencyEnrolledDMEDurable Medical EquipmentEnrolledPMDPower Mobility DeviceEnrolledCMS last updated its PECOS records 3 days ago.Profile DetailsProvider ID1588493050Provider TypeIndividualFull NameKelly, NicoleCredentialPA-CGenderFemaleSole ProprietorNoEnumeration Date7/31/2024Last Updated10/8/2024Contact InformationPractice LocationPractice Address3181 SW Sam Jackson Park Rd, Portland, OR 97239-3011Phone(503) 494-4314FaxUnlisted FaxMailing LocationMailing Address1400 SW 5th Ave Ste 500, Portland, OR 97201-5537Phone(866) 617-6855Fax(503) 346-8015Provider TaxonomiesCodeDescriptionLicenseCode363AM0700XPrimaryDescriptionPhysician AssistantPhysician Assistants & Advanced Practice Nursing ProvidersLicensePA220357OregonCode363A00000XDescriptionPhysician AssistantPhysician Assistants & Advanced Practice Nursing ProvidersLicenseUnlisted Issuer