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General NPI Number Information
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NPI Number | 1144767344
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Entity Type | Individual
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Provider Name | KELLY D JENNE NP
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Gender | Female
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Dates
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Enumeration Date | 01/25/2017
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Last Update Date | 10/08/2024
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Provider Practice Location Address
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Address Line | 314 1ST ST E
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City | POLSON
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State | MT
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Zip | 59860-2148
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Country | US
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Telephone | 406-880-6415
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Fax |
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Provider Business Mailing Address
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Address Line | 250 N SHADELAND AVE
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City | INDIANAPOLIS
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State | IN
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Zip | 46219-4959
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 28209377A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 71007550A
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License Number State | IN
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Taxonomy #3
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 220320
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License Number State | MT
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