Basic Information
| Provider Information | |||||||||
| NPI: | 1003284449 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ECCLES | ||||||||
| FirstName: | KELLI | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3011 N MICHIGAN ST | ||||||||
| Address2: | |||||||||
| City: | PITTSBURG | ||||||||
| State: | KS | ||||||||
| PostalCode: | 667622546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202319873 | ||||||||
| FaxNumber: | 6202312808 | ||||||||
| Practice Location | |||||||||
| Address1: | 2051 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | IOLA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 667491677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6203806600 | ||||||||
| FaxNumber: | 6203806215 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2015 | ||||||||
| LastUpdateDate: | 08/18/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SE0003X | 76903 | KS | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Emergency | 364SF0001X | 76903 | KS | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Family Health | 363LF0000X | 76903 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 76903 | 01 | KS | STATE LICENSE | OTHER |