Healthcare Provider Details

I. General information

NPI: 1871405852
Provider Name (Legal Business Name): KELLIE BAKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 DIVISION ST
UPTON WY
82730-5055
US

IV. Provider business mailing address

PO BOX 82
UPTON WY
82730-0082
US

V. Phone/Fax

Practice location:
  • Phone: 307-629-4312
  • Fax:
Mailing address:
  • Phone: 307-629-4312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: