Healthcare Provider Details

I. General information

NPI: 1174034961
Provider Name (Legal Business Name): KELLY RAWE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY CAUDILL APRN

II. Dates (important events)

Enumeration Date: 10/19/2017
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL VILLAGE DR
EDGEWOOD KY
41017-3403
US

IV. Provider business mailing address

PO BOX 635283
CINCINNATI OH
45263-5283
US

V. Phone/Fax

Practice location:
  • Phone: 859-301-5652
  • Fax:
Mailing address:
  • Phone: 859-301-5652
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3011602
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: