Provider Demographics
NPI:1740786631
Name:BLOCK, KELLY LAUREN (DO)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LAUREN
Last Name:BLOCK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 190930
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-0930
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:1072 N LIBERTY ST STE 303
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8708
Practice Address - Country:US
Practice Address - Phone:208-302-4200
Practice Address - Fax:208-302-4255
Is Sole Proprietor?:No
Enumeration Date:2018-04-01
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO2095002084N0400X
390200000X
IDO-19682084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program