1790322436 NPI number — KELLY JOHN

Table of content: KELLY JOHN (NPI 1790322436)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790322436 NPI number — KELLY JOHN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHN
Provider First Name:
KELLY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790322436
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/12/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
850 W IRONWOOD DR STE 202
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COEUR D ALENE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83814-4903
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-664-2175
Provider Business Mailing Address Fax Number:
208-664-1226

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8468 N WAYNE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAYDEN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83835-6025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-601-6060
Provider Business Practice Location Address Fax Number:
208-635-5098
Provider Enumeration Date:
12/02/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PT7061 . This is a "STATE LICENSE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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