Healthcare Provider Details

I. General information

NPI: 1184255408
Provider Name (Legal Business Name): KELLY MARIE ANDERSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2020
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3015 10TH ST STE A
COLUMBUS IN
47201-7091
US

IV. Provider business mailing address

PO BOX 775383
CHICAGO IL
60677-5383
US

V. Phone/Fax

Practice location:
  • Phone: 812-372-8883
  • Fax:
Mailing address:
  • Phone: 812-376-3515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28216712A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71010494A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: