1184668063 NPI number — MARY LOU KELSEY ANP CNM RN

Table of content: MARY LOU KELSEY ANP CNM RN (NPI 1184668063)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184668063 NPI number — MARY LOU KELSEY ANP CNM RN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELSEY
Provider First Name:
MARY LOU
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ANP CNM RN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184668063
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/20/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4136 BARTLETT ST
Provider Second Line Business Mailing Address:
HOMER MEDICAL CLINIC
Provider Business Mailing Address City Name:
HOMER
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99603
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-235-8586
Provider Business Mailing Address Fax Number:
907-235-6639

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4136 BARTLETT ST
Provider Second Line Business Practice Location Address:
HOMER MEDICAL CLINIC
Provider Business Practice Location Address City Name:
HOMER
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-235-8586
Provider Business Practice Location Address Fax Number:
907-235-6639
Provider Enumeration Date:
06/15/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  RN8404 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367A00000X , with the licence number: NP47 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: MK0010164 . This is a "USDA" identifier . This identifiers is of the category "OTHER".
  • Identifier: NM0188 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".