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Individual
KELLY D JENNE
Active
Individual
KELLY D JENNE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
NP
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
220320
MT
363LF0000X
Family Nurse Practitioner
28209377A
IN
363LF0000X
Family Nurse Practitioner
71007550A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
068010568
MEDICARE PTAN
IN
01
—
090540375
MEDICARE PTAN
IN
05
—
300008240
—
IN
01
—
P02474299
RAILROAD PTAN
IN
Enumeration date
01/25/2017
Last updated
10/08/2024
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