MEDICARE: KELLIE PLANCK

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	363LF0000X	Family Nurse Practitioner	71006172A	IN
2	363L00000X	Nurse Practitioner	71006172A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0000001008936	OTHER	IN	ANTHEM
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1144680679
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLIE PLANCK

Provider Business Mailing Address
First Line	:	330 N WABASH
Second Line	:	STE G20
City	:	MARION
State	:	IN
Zip	:	46952-2600
Country	:	US
Telephone Number	:	765-660-7616
Fax Number	:	765-651-7313

Provider Business Practice Location Address
First Line	:	4781 KAYBEE DRIVE
Second Line	:
City	:	GAS CITY
State	:	IN
Zip	:	46933-6607
Country	:	US
Telephone Number	:	765-660-7840
Fax Number	:	765-671-3509

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

Provider Enumeration Date	:	02/25/2016
Last Update Date	:	10/20/2020

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Directions to “ KELLIE PLANCK ” Practice Location

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