Healthcare Provider Details

I. General information

NPI: 1174872600
Provider Name (Legal Business Name): JENNY LYNN KELLY APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2012
Last Update Date: 11/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2845 GREENBRIER RD
GREEN BAY WI
54311-6519
US

IV. Provider business mailing address

164 N BROADWAY
GREEN BAY WI
54303-2728
US

V. Phone/Fax

Practice location:
  • Phone: 920-288-4060
  • Fax: 920-288-4067
Mailing address:
  • Phone: 920-965-4055
  • Fax: 920-405-5388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4936-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: