Provider Demographics
NPI:1417488222
Name:SUN, KELLY RENEE (DO)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:RENEE
Last Name:SUN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:RENEE
Other - Last Name:BIEDENHARN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-344-5555
Mailing Address - Fax:859-344-5552
Practice Address - Street 1:334 THOMAS MORE PKWY
Practice Address - Street 2:
Practice Address - City:CRESTVIEW HILLS
Practice Address - State:KY
Practice Address - Zip Code:41017-3464
Practice Address - Country:US
Practice Address - Phone:593-410-2888
Practice Address - Fax:859-341-7482
Is Sole Proprietor?:No
Enumeration Date:2017-03-23
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KYTP658207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program