Healthcare Provider Details

I. General information

NPI: 1437526894
Provider Name (Legal Business Name): KELLI S LANDRUM FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLI S VICEK FNP-C

II. Dates (important events)

Enumeration Date: 09/01/2015
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 FRONTAGE RD
KENAI AK
99611
US

IV. Provider business mailing address

PO BOX 2949
SOLDOTNA AK
99669-2949
US

V. Phone/Fax

Practice location:
  • Phone: 907-283-3600
  • Fax: 907-283-3601
Mailing address:
  • Phone: 907-260-7303
  • Fax: 907-260-7301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201506440NP-PP
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number227339
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number133545
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: