Provider Demographics
NPI:1598987307
Name:STANKIEWICZ, KELLY J (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:J
Last Name:STANKIEWICZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1526 UTE BLVD
Mailing Address - Street 2:STE 104
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-7575
Mailing Address - Country:US
Mailing Address - Phone:317-445-3555
Mailing Address - Fax:
Practice Address - Street 1:2155 CITY GATE LN STE 225
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-7770
Practice Address - Country:US
Practice Address - Phone:630-547-5040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2017-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036128182207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology