Provider Demographics
NPI:1184780694
Name:PALMER, KELLY PAGE (DO)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:PAGE
Last Name:PALMER
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:PO BOX 400
Mailing Address - Street 2:700 EAST ALICE
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-0400
Mailing Address - Country:US
Mailing Address - Phone:208-785-8517
Mailing Address - Fax:208-785-8516
Practice Address - Street 1:700 EAST ALICE STREET
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-0400
Practice Address - Country:US
Practice Address - Phone:208-785-8517
Practice Address - Fax:208-785-8516
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2012-08-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IDO-1442084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003398400Medicaid
ID0033991Medicaid