Healthcare Provider Details

I. General information

NPI: 1205776705
Provider Name (Legal Business Name): KELLY STACKHOUSE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2026
Last Update Date: 04/01/2026
Certification Date: 04/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 15TH ST NW STE 410
WASHINGTON DC
20005-2899
US

IV. Provider business mailing address

3510 KEARNEY ST
DENVER CO
80207-1320
US

V. Phone/Fax

Practice location:
  • Phone: 914-821-8993
  • Fax:
Mailing address:
  • Phone: 617-538-4131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0200X
TaxonomyOncology Registered Nurse
License Number1634000
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: