Provider Demographics
NPI:1376946780
Name:KESSEN, KELLY (LAC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KESSEN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38148 BOULDER CANYON DR
Mailing Address - Street 2:APT A
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-9645
Mailing Address - Country:US
Mailing Address - Phone:303-578-0895
Mailing Address - Fax:
Practice Address - Street 1:1800 30TH ST
Practice Address - Street 2:SUITE 309
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1088
Practice Address - Country:US
Practice Address - Phone:303-578-0895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-29
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACU.0001921171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist