Provider Demographics
NPI:1902892094
Name:PRINGLE, KELLY N (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:N
Last Name:PRINGLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6879
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-212-5116
Practice Address - Street 1:100 MALLARD CREEK RD STE 395
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-5167
Practice Address - Country:US
Practice Address - Phone:502-895-9421
Practice Address - Fax:502-899-5762
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35844208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN50015980OtherPASSPORT - CMA
IN200878520Medicaid
IN000000533403OtherANTHEM - CMA
IN090052OtherSIHO - CMA
IN090052OtherSIHO - CMA
LA1641821Medicaid
IN196290PPPMedicare PIN
IN50015980OtherPASSPORT - CMA
LAI39523Medicare UPIN