Healthcare Provider Details

I. General information

NPI: 1891488433
Provider Name (Legal Business Name): ELITE PROFESSIONAL PROVIDERS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2023
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3322 S CAMPBELL AVE STE T-1
SPRINGFIELD MO
65807-4980
US

IV. Provider business mailing address

2135 E INDEPENDENCE ST # 1093
SPRINGFIELD MO
65804-3749
US

V. Phone/Fax

Practice location:
  • Phone: 417-220-4482
  • Fax: 417-414-0017
Mailing address:
  • Phone: 417-220-4482
  • Fax: 417-414-0017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SHAWN KELLEY
Title or Position: COO
Credential:
Phone: 417-220-4482