Healthcare Provider Details

I. General information

NPI: 1467958975
Provider Name (Legal Business Name): KELLIE R. PARKER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLIE R. SWAFFORD

II. Dates (important events)

Enumeration Date: 04/03/2018
Last Update Date: 04/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 PROVIDENT DR
WARSAW IN
46580-3265
US

IV. Provider business mailing address

2518 E DUPONT RD
FORT WAYNE IN
46825-1675
US

V. Phone/Fax

Practice location:
  • Phone: 574-269-4026
  • Fax: 574-269-7444
Mailing address:
  • Phone: 260-432-4400
  • Fax: 260-969-6898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71007937A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: