Healthcare Provider Details

I. General information

NPI: 1396032017
Provider Name (Legal Business Name): KELLY LEANNE CARDEN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2011
Last Update Date: 07/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 MICHIGAN AVE SUITE 270
LOGANSPORT IN
46947-1580
US

IV. Provider business mailing address

1201 MICHIGAN AVE SUITE 270
LOGANSPORT IN
46947-1580
US

V. Phone/Fax

Practice location:
  • Phone: 574-722-4921
  • Fax:
Mailing address:
  • Phone: 574-722-4921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28135764A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: