Provider Demographics
NPI:1396242228
Name:KELVAS, DANIELLE ELIZABETH (MD)
Entity type:Individual
Prefix:DR
First Name:DANIELLE
Middle Name:ELIZABETH
Last Name:KELVAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:DANIELLE
Other - Middle Name:ELIZABETH
Other - Last Name:KELVAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:623 W MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6605
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2614 FORUM BLVD STE 100
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-5431
Practice Address - Country:US
Practice Address - Phone:573-445-5366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-08
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2020011369208D00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program