Healthcare Provider Details

I. General information

NPI: 1609247980
Provider Name (Legal Business Name): KELSEY KUYKENDALL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2015
Last Update Date: 10/07/2021
Certification Date: 10/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

816 ACOMA ST UNIT 1117
DENVER CO
80204-4010
US

IV. Provider business mailing address

8625 SW CASCADE AVE STE 320
BEAVERTON OR
97008-7126
US

V. Phone/Fax

Practice location:
  • Phone: 417-262-3204
  • Fax:
Mailing address:
  • Phone: 877-755-8940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: