Provider Demographics
NPI:1407258809
Name:FENTON, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:FENTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32105 E 155TH ST
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:MO
Mailing Address - Zip Code:64080-8620
Mailing Address - Country:US
Mailing Address - Phone:816-589-0902
Mailing Address - Fax:
Practice Address - Street 1:32105 E 155TH ST
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:MO
Practice Address - Zip Code:64080-8620
Practice Address - Country:US
Practice Address - Phone:816-589-0902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-17
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO099428163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse