Provider Demographics
NPI:1366443699
Name:CHRISTENSEN, KELLI DEANNE (MD)
Entity Type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:DEANNE
Last Name:CHRISTENSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:KELLI
Other - Middle Name:D
Other - Last Name:NICHOLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2850 OLYMPUS DR.
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201
Mailing Address - Country:US
Mailing Address - Phone:208-239-3815
Mailing Address - Fax:208-239-3814
Practice Address - Street 1:2850 OLYMPUS DR.
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-239-3815
Practice Address - Fax:208-239-3814
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM9428207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1366443699Medicaid
ID8070707000Medicaid
IDOTH00000Medicare UPIN