Basic Information
| Provider Information | |||||||||
| NPI: | 1144761057 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PRATHER | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 781076 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482781076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175284800 | ||||||||
| FaxNumber: | 3178651479 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 HADLEY RD | ||||||||
| Address2: | |||||||||
| City: | MOORESVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461581737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178343263 | ||||||||
| FaxNumber: | 3178345194 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2017 | ||||||||
| LastUpdateDate: | 03/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 71001368A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.