Provider Demographics
NPI:1780211334
Name:KELTNER, KATELYN TAYLOR (PA)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:TAYLOR
Last Name:KELTNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 N FOXRIDGE DR APT 205
Mailing Address - Street 2:
Mailing Address - City:RAYMORE
Mailing Address - State:MO
Mailing Address - Zip Code:64083-7833
Mailing Address - Country:US
Mailing Address - Phone:816-813-0607
Mailing Address - Fax:
Practice Address - Street 1:1950 DIAMOND PKWY
Practice Address - Street 2:
Practice Address - City:NORTH KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64116-4328
Practice Address - Country:US
Practice Address - Phone:816-561-3003
Practice Address - Fax:816-889-1584
Is Sole Proprietor?:No
Enumeration Date:2020-03-24
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2020028651363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program