Basic Information
| Provider Information | |||||||||
| NPI: | 1487616553 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLAUSEN | ||||||||
| FirstName: | KELLIE | ||||||||
| MiddleName: | DALE | ||||||||
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| Credential: | F.N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 S 5TH ST | ||||||||
| Address2: | |||||||||
| City: | DOUGLAS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826332434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073582122 | ||||||||
| FaxNumber: | 3073587381 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 S 5TH ST | ||||||||
| Address2: | |||||||||
| City: | DOUGLAS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826332434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073582122 | ||||||||
| FaxNumber: | 3073587381 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2006 | ||||||||
| LastUpdateDate: | 01/05/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 14471-0152 | WY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 121710100 | 05 | WY | MEDICAID | 313807 | 01 | WY | BLUECROSS AND BLUESHIELD | OTHER |