MEDICARE: MS. WANDA ELAINE KELLEY NURSE PRACTITIONER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	63998	CO
2	363LF0000X	Family Nurse Practitioner	109125-22	CO

General Provider Information

NPI Number	:	1033153804
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. WANDA ELAINE KELLEY NURSE PRACTITIONER

Provider Business Mailing Address
First Line	:	2708 HIGH PLAINS CT
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80526-6501
Country	:	US
Telephone Number	:	970-223-6753
Fax Number	:	970-266-1302

Provider Business Practice Location Address
First Line	:	COLORADO STATE UNIVERSITY HARTSHORN HEALTH SERVICE
Second Line	:	8031 CAMPUS DELIVERY
City	:	FORT COLLINS
State	:	CO
Zip	:	80523-0001
Country	:	US
Telephone Number	:	970-491-7121
Fax Number	:	970-491-0268

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2006
Last Update Date	:	09/11/2025

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