Provider Demographics
NPI:1417081878
Name:PAULSEN, KELLY (DC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:PAULSEN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WAUCONDA
Mailing Address - State:IL
Mailing Address - Zip Code:60084-1809
Mailing Address - Country:US
Mailing Address - Phone:847-526-4040
Mailing Address - Fax:847-487-5101
Practice Address - Street 1:105 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WAUCONDA
Practice Address - State:IL
Practice Address - Zip Code:60084-1809
Practice Address - Country:US
Practice Address - Phone:847-526-4040
Practice Address - Fax:847-487-5101
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL049-01053OtherBLUE CROSS BLUE SHIELD
IL049-01053OtherBLUE CROSS BLUE SHIELD