Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | 71004900A | IN |
NPI | 1003228446 |
---|---|
Provider Name | Kelly Kelly |
First Address | Evansville, IN 47714-5559 |
Second Address | Evansville, IN 47714-5559 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/05/2014 |
Last Update Date | 17/03/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
28184683A | INDIANA (01) | IN |