Healthcare Provider Details

I. General information

NPI: 1184668063
Provider Name (Legal Business Name): MARY LOU KELSEY ANP CNM RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 08/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4136 BARTLETT ST HOMER MEDICAL CLINIC
HOMER AK
99603
US

IV. Provider business mailing address

4136 BARTLETT ST HOMER MEDICAL CLINIC
HOMER AK
99603
US

V. Phone/Fax

Practice location:
  • Phone: 907-235-8586
  • Fax: 907-235-6639
Mailing address:
  • Phone: 907-235-8586
  • Fax: 907-235-6639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberNP47
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN8404
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: