Healthcare Provider Details

I. General information

NPI: 1992261002
Provider Name (Legal Business Name): KELLIE GOEDKEN DEN HARTOG PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLIE ANN GOEDKEN

II. Dates (important events)

Enumeration Date: 02/13/2019
Last Update Date: 02/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 S 10TH AVE
ROCK RAPIDS IA
51246-2020
US

IV. Provider business mailing address

1363 HIGHWAY 9 APT 5
LARCHWOOD IA
51241-7585
US

V. Phone/Fax

Practice location:
  • Phone: 712-472-5399
  • Fax:
Mailing address:
  • Phone: 712-348-3341
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number095185
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: