Provider Demographics
NPI:1912862830
Name:KELLEY, KRISTINE
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 N IOWA ST
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66061-3216
Mailing Address - Country:US
Mailing Address - Phone:480-203-6914
Mailing Address - Fax:
Practice Address - Street 1:15512 W 113TH ST
Practice Address - Street 2:
Practice Address - City:LENEXA
Practice Address - State:KS
Practice Address - Zip Code:66219-5100
Practice Address - Country:US
Practice Address - Phone:816-922-2522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-12-23
Last Update Date:2025-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSK04-61-8789172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver