Healthcare Provider Details

I. General information

NPI: 1629296603
Provider Name (Legal Business Name): TRACE KELLY FNP-C, DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 07/07/2021
Certification Date: 07/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4613 ROXANN BLVD STE 101
LOUISVILLE KY
40218-4072
US

IV. Provider business mailing address

4227 POPLAR LEVEL RD
LOUISVILLE KY
40213-1527
US

V. Phone/Fax

Practice location:
  • Phone: 502-415-3943
  • Fax: 502-451-5041
Mailing address:
  • Phone: 502-451-5959
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number4973
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3015925
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: