Healthcare Provider Details

I. General information

NPI: 1851192215
Provider Name (Legal Business Name): KELLI DAAKE
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2025
Last Update Date: 03/21/2025
Certification Date: 03/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2208 N WEBB RD UNIT 4
GRAND ISLAND NE
68803-1756
US

IV. Provider business mailing address

3015 W NORTH FRONT ST APT 4
GRAND ISLAND NE
68803-4056
US

V. Phone/Fax

Practice location:
  • Phone: 402-698-9812
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: