Provider Demographics
NPI:1386030526
Name:DEFOREST, PATRICIA KELLEY (DO)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:KELLEY
Last Name:DEFOREST
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-2905
Mailing Address - Country:US
Mailing Address - Phone:573-426-3225
Mailing Address - Fax:573-202-2444
Practice Address - Street 1:1050 W 10TH ST
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-2905
Practice Address - Country:US
Practice Address - Phone:573-426-3225
Practice Address - Fax:573-202-2444
Is Sole Proprietor?:No
Enumeration Date:2015-04-14
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR7197208000000X
MO2020039826208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics