Provider Demographics
NPI:1699081083
Name:KELLENBECK, ERICA SANDE (MD)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:SANDE
Last Name:KELLENBECK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ERICA
Other - Middle Name:SANDE
Other - Last Name:ASHENBRENER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2003 KOOTENAI HEALTH WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-6051
Mailing Address - Country:US
Mailing Address - Phone:208-625-5085
Mailing Address - Fax:208-625-5731
Practice Address - Street 1:2003 KOOTENAI HEALTH WAY
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-6051
Practice Address - Country:US
Practice Address - Phone:208-625-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-24
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM13204207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program