1235246729 NPI number — MRS. JARENA JAN KELLY DNP,APRN-BC

Table of content: MRS. JARENA JAN KELLY DNP,APRN-BC (NPI 1235246729)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235246729 NPI number — MRS. JARENA JAN KELLY DNP,APRN-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLY
Provider First Name:
JARENA
Provider Middle Name:
JAN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
DNP,APRN-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GIBSON
Provider Other First Name:
JARENA
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1235246729
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4605 MACCORKLE AVE SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH CHARLESTON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25309-1311
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-414-4800
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
506 CHESTNUT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH CHARLESTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25309-1204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-766-8558
Provider Business Practice Location Address Fax Number:
304-766-8561
Provider Enumeration Date:
08/23/2006

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: 363LF0000X , with the licence number:  41613 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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