Provider Demographics
NPI:1730698952
Name:ROCK, KELLIE LEE (RN)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:LEE
Last Name:ROCK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:LEE
Other - Last Name:FREEMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:96 CLINIC RD N
Mailing Address - Street 2:
Mailing Address - City:BOX ELDER
Mailing Address - State:MT
Mailing Address - Zip Code:59521-8849
Mailing Address - Country:US
Mailing Address - Phone:406-395-4486
Mailing Address - Fax:406-395-4138
Practice Address - Street 1:96 CLINIC RD N
Practice Address - Street 2:
Practice Address - City:BOX ELDER
Practice Address - State:MT
Practice Address - Zip Code:59521-8849
Practice Address - Country:US
Practice Address - Phone:406-395-4486
Practice Address - Fax:406-395-4138
Is Sole Proprietor?:No
Enumeration Date:2017-09-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT17988163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT17988OtherRN