Provider Demographics
NPI:1558179697
Name:BOTRUFF, KELSEY A (HIS)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:A
Last Name:BOTRUFF
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 W 35TH ST STE STE 2
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52806-5820
Mailing Address - Country:US
Mailing Address - Phone:563-386-8885
Mailing Address - Fax:
Practice Address - Street 1:430 W 35TH ST STE STE 2
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52806-5820
Practice Address - Country:US
Practice Address - Phone:563-386-8885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-20
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA130009237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty