Provider Demographics
NPI:1669147344
Name:LINEBACK, KELSIE JEAN (DHA)
Entity type:Individual
Prefix:DR
First Name:KELSIE
Middle Name:JEAN
Last Name:LINEBACK
Suffix:
Gender:F
Credentials:DHA
Other - Prefix:
Other - First Name:KELSIE
Other - Middle Name:JEAN
Other - Last Name:BOOKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14122 3RD ST BLDG 350
Mailing Address - Street 2:
Mailing Address - City:FORT LEONARD WOOD
Mailing Address - State:MO
Mailing Address - Zip Code:65473-9167
Mailing Address - Country:US
Mailing Address - Phone:573-596-9677
Mailing Address - Fax:
Practice Address - Street 1:14122 3RD ST BLDG 350
Practice Address - Street 2:
Practice Address - City:FORT LEONARD WOOD
Practice Address - State:MO
Practice Address - Zip Code:65473-9167
Practice Address - Country:US
Practice Address - Phone:573-596-9677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-13
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator