MEDICARE: KELLY MCKINNEY 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	363LF0000X	Family Nurse Practitioner	2015028839	MO
2	363LA2200X	Adult Health Nurse Practitioner	2015028839	MO
3	363L00000X	Nurse Practitioner	2015028839	MO
4	363LP2300X	Primary Care Nurse Practitioner	2015028839	MO

General Provider Information

NPI Number	:	1376929760
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY MCKINNEY NP

Provider Business Mailing Address
First Line	:	1225 GRAHAM RD STE 230C
Second Line	:
City	:	FLORISSANT
State	:	MO
Zip	:	63031-8012
Country	:	US
Telephone Number	:	314-953-6801
Fax Number	:	314-953-8272

Provider Business Practice Location Address
First Line	:	1225 GRAHAM RD STE C-1340
Second Line	:
City	:	FLORISSANT
State	:	MO
Zip	:	63031-8019
Country	:	US
Telephone Number	:	314-953-6801
Fax Number	:

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

Provider Enumeration Date	:	08/07/2015
Last Update Date	:	04/10/2026

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