Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | 76903 | KS |
NPI | 1003284449 |
---|---|
Provider Name | Kelli Eccles |
First Address | Pittsburg, KS 66762-2546 |
Second Address | Iola, KS 66749-1677 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/09/2015 |
Last Update Date | 18/08/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
76903 | STATE LICENSE (01) | KS |