Healthcare Provider Details

I. General information

NPI: 1407184831
Provider Name (Legal Business Name): KELLI LYNN QUEEN NNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/23/2009
Last Update Date: 05/13/2025
Certification Date: 05/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 STADIUM DRIVE
MORGANTOWN WV
26506-0000
US

IV. Provider business mailing address

PO BOX 780
MORGANTOWN WV
26506-0000
US

V. Phone/Fax

Practice location:
  • Phone: 304-598-4000
  • Fax:
Mailing address:
  • Phone: 304-293-7401
  • Fax: 304-293-6963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number62992
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number0024168702
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: