Healthcare Provider Details

I. General information

NPI: 1104243245
Provider Name (Legal Business Name): KELSTAN LYNCH ELLIS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2014
Last Update Date: 01/21/2022
Certification Date: 01/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 GILLHAM RD
KANSAS CITY MO
64108-4619
US

IV. Provider business mailing address

2401 GILLHAM RD
KANSAS CITY MO
64108-4619
US

V. Phone/Fax

Practice location:
  • Phone: 816-302-8613
  • Fax: 816-588-1985
Mailing address:
  • Phone: 816-302-8613
  • Fax: 816-588-1985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080H0002X
TaxonomyPediatric Hospice and Palliative Medicine Physician
License Number2018015474
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: