Provider Demographics
NPI:1902366313
Name:KIRK, KELLY RENEE (DO)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:RENEE
Last Name:KIRK
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 1:1108 VESTER AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-1302
Mailing Address - Country:US
Mailing Address - Phone:937-399-7100
Mailing Address - Fax:937-399-7355
Practice Address - Street 1:1108 VESTER AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-1302
Practice Address - Country:US
Practice Address - Phone:937-399-7100
Practice Address - Fax:937-399-7355
Is Sole Proprietor?:No
Enumeration Date:2019-03-21
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH34.016559207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program