Healthcare Provider Details

I. General information

NPI: 1396242228
Provider Name (Legal Business Name): DANIELLE ELIZABETH KELVAS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DANIELLE ELIZABETH KELVAS MD

II. Dates (important events)

Enumeration Date: 04/08/2018
Last Update Date: 08/17/2021
Certification Date: 08/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2614 FORUM BLVD STE 100
COLUMBIA MO
65203-5431
US

IV. Provider business mailing address

623 W MAPLE ST
JOHNSON CITY TN
37604-6605
US

V. Phone/Fax

Practice location:
  • Phone: 573-445-5366
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number2020011369
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: