Basic Information
| Provider Information | |||||||||
| NPI: | 1083082499 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | KELLIAN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | APRN, FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1516 SW 6TH AVE | ||||||||
| Address2: | |||||||||
| City: | TOPEKA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 666061696 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7852700047 | ||||||||
| FaxNumber: | 7852700086 | ||||||||
| Practice Location | |||||||||
| Address1: | 1516 SW 6TH AVE | ||||||||
| Address2: | |||||||||
| City: | TOPEKA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 666061696 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7852700047 | ||||||||
| FaxNumber: | 7852700086 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2015 | ||||||||
| LastUpdateDate: | 08/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 53-76919-092 | KS | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 76919 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 201133480A | 05 | KS | MEDICAID |