Healthcare Provider Details

I. General information

NPI: 1639209174
Provider Name (Legal Business Name): DEAN M KELLY ANP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 12/11/2019
Certification Date: 12/11/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3218 DAUGHERTY DR STE 140
LAFAYETTE IN
47909-3997
US

IV. Provider business mailing address

760 PARK EAST BLVD STE 5
LAFAYETTE IN
47905-0796
US

V. Phone/Fax

Practice location:
  • Phone: 765-502-4190
  • Fax: 765-502-4191
Mailing address:
  • Phone: 765-447-7473
  • Fax: 765-449-8504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0106X
TaxonomyOccupational Health Nurse Practitioner
License Number71000948B
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: