MEDICARE: KELLY MIKE NP

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	363LG0600X	Gerontology Nurse Practitioner	3008550	KY
2	363LA2200X	Adult Health Nurse Practitioner	APN3008550	KY

General Provider Information

NPI Number	:	1073939468
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY MIKE NP

Provider Business Mailing Address
First Line	:	PO BOX 740017
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-0017
Country	:	US
Telephone Number	:	312-733-0373
Fax Number	:

Provider Business Practice Location Address
First Line	:	1731 DIXIE HWY
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40210-2313
Country	:	US
Telephone Number	:	502-444-6016
Fax Number	:

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

Provider Enumeration Date	:	03/10/2014
Last Update Date	:	08/07/2024

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Directions to “ KELLY MIKE NP” Practice Location

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