Healthcare Provider Details

I. General information

NPI: 1356964464
Provider Name (Legal Business Name): KELLY GEBAUER WHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2020
Last Update Date: 01/24/2025
Certification Date: 01/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 E CARLSON ST STE 102
CHEYENNE WY
82009-4335
US

IV. Provider business mailing address

611 E CARLSON ST STE 102
CHEYENNE WY
82009-4335
US

V. Phone/Fax

Practice location:
  • Phone: 307-364-3415
  • Fax: 307-296-0349
Mailing address:
  • Phone: 307-364-3415
  • Fax: 307-296-0349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License Number22963
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number47173
License Number StateWY
# 3
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number47173
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: