Healthcare Provider Details

I. General information

NPI: 1205618410
Provider Name (Legal Business Name): CARLY ELIZABETH KESSINGER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2023
Last Update Date: 11/07/2023
Certification Date: 11/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3118 E 10TH ST
JEFFERSONVILLE IN
47130-5904
US

IV. Provider business mailing address

PO BOX 776351
CHICAGO IL
60677-5904
US

V. Phone/Fax

Practice location:
  • Phone: 812-282-6979
  • Fax:
Mailing address:
  • Phone: 502-588-9490
  • Fax: 502-272-5339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71014514A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number71014514A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: