Provider Demographics
NPI:1992261002
Name:DEN HARTOG, KELLIE GOEDKEN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KELLIE
Middle Name:GOEDKEN
Last Name:DEN HARTOG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:ANN
Other - Last Name:GOEDKEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1363 HIGHWAY 9 APT 5
Mailing Address - Street 2:
Mailing Address - City:LARCHWOOD
Mailing Address - State:IA
Mailing Address - Zip Code:51241-7585
Mailing Address - Country:US
Mailing Address - Phone:712-348-3341
Mailing Address - Fax:
Practice Address - Street 1:1100 S 10TH AVE
Practice Address - Street 2:
Practice Address - City:ROCK RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:51246-2020
Practice Address - Country:US
Practice Address - Phone:712-472-5399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-13
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA095185207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine