Healthcare Provider Details

I. General information

NPI: 1154956530
Provider Name (Legal Business Name): KELLY CELESTE MCLEAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2020
Last Update Date: 11/04/2022
Certification Date: 11/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 COLORADO AVE
PUEBLO CO
81004-2006
US

IV. Provider business mailing address

110 E ROUTT AVE
PUEBLO CO
81004-2117
US

V. Phone/Fax

Practice location:
  • Phone: 719-543-8711
  • Fax: 719-543-0171
Mailing address:
  • Phone: 719-543-8711
  • Fax: 719-585-3057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPN.0997934-NP
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number1657498
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: