1639209174 NPI number — DEAN M KELLY ANP

Table of content: DEAN M KELLY ANP (NPI 1639209174)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639209174 NPI number — DEAN M KELLY ANP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLY
Provider First Name:
DEAN
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ANP
Provider Gender Code:
M

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:
1639209174
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
760 PARK EAST BLVD STE 5
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47905-0796
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-447-7473
Provider Business Mailing Address Fax Number:
765-449-8504

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3218 DAUGHERTY DR STE 140
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47909-3997
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-502-4190
Provider Business Practice Location Address Fax Number:
765-502-4191
Provider Enumeration Date:
03/06/2007

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: 363LX0106X , with the licence number:  71000948B , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000599883 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000625966 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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