Provider Demographics
NPI:1073279568
Name:BUNTAINE, KELLI ELIZABETH (FNP-C)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:ELIZABETH
Last Name:BUNTAINE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2991 HIGHWAY K
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-7862
Mailing Address - Country:US
Mailing Address - Phone:636-435-2333
Mailing Address - Fax:314-626-8009
Practice Address - Street 1:2991 HIGHWAY K
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-7862
Practice Address - Country:US
Practice Address - Phone:636-435-2333
Practice Address - Fax:314-626-8009
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-09
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO149260163WE0003X
MO2022015784363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency