Provider Demographics
NPI:1255575718
Name:QUAKENBUSH, KELLY LYNN (DO)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:QUAKENBUSH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:LYNN
Other - Last Name:IRVIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:111 DALLAS ST STE 201
Mailing Address - Street 2:
Mailing Address - City:ARGYLE
Mailing Address - State:TX
Mailing Address - Zip Code:76226
Mailing Address - Country:US
Mailing Address - Phone:940-277-7373
Mailing Address - Fax:214-279-7556
Practice Address - Street 1:111 DALLAS ST STE 201
Practice Address - Street 2:
Practice Address - City:ARGYLE
Practice Address - State:TX
Practice Address - Zip Code:76226
Practice Address - Country:US
Practice Address - Phone:940-277-7373
Practice Address - Fax:214-279-7556
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-28
Last Update Date:2024-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ00752084P0800X, 2084P0800X
NC2019-000402084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry