Healthcare Provider Details

I. General information

NPI: 1144767344
Provider Name (Legal Business Name): KELLY D JENNE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLY D KASTING

II. Dates (important events)

Enumeration Date: 01/25/2017
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 1ST ST E
POLSON MT
59860-2148
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 406-880-6415
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number220320
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28209377A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71007550A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: