Healthcare Provider Details

I. General information

NPI: 1972334282
Provider Name (Legal Business Name): CASSANDRA L. KELLAMS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2024
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 W 1ST ST
BLOOMINGTON IN
47403-2504
US

IV. Provider business mailing address

10782 W OLD VINCENNES RD
WEST BADEN SPRINGS IN
47469-9669
US

V. Phone/Fax

Practice location:
  • Phone: 812-668-1946
  • Fax: 812-287-8438
Mailing address:
  • Phone: 812-508-1143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71016302A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: