Healthcare Provider Details

I. General information

NPI: 1790429504
Provider Name (Legal Business Name): KELSEY KUIPERS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2022
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 LINCOLN WAY STE 315
COEUR D ALENE ID
83814-2527
US

IV. Provider business mailing address

24589 TIFFANY LN
HERMOSA SD
57744-7514
US

V. Phone/Fax

Practice location:
  • Phone: 208-625-6029
  • Fax:
Mailing address:
  • Phone: 605-391-8310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM-17751
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberM-17751
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: