Provider Demographics
NPI:1700311974
Name:FERRELL, KELSEY (DO)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:FERRELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:
Other - Last Name:BRUCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:2535 E FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7319
Mailing Address - Country:US
Mailing Address - Phone:208-519-4333
Mailing Address - Fax:208-205-9134
Practice Address - Street 1:2535 E FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:208-519-4333
Practice Address - Fax:208-205-9134
Is Sole Proprietor?:No
Enumeration Date:2017-04-25
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO188724207N00000X
ORPG182903207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine