Provider Demographics
NPI:1023604873
Name:FOREST, KELLYLYNNE (CPHT)
Entity type:Individual
Prefix:
First Name:KELLYLYNNE
Middle Name:
Last Name:FOREST
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10411 TOWNER AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-3060
Mailing Address - Country:US
Mailing Address - Phone:541-250-2345
Mailing Address - Fax:
Practice Address - Street 1:123 MADEIRA DR SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-2963
Practice Address - Country:US
Practice Address - Phone:505-262-1538
Practice Address - Fax:505-243-5342
Is Sole Proprietor?:No
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZT066714183700000X
NMPT00013188183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician