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NPI Code Detail

MEDICARE: KELLY EILEEN CHURCH FNP

MEDICARE: KELLY EILEEN CHURCH FNP
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
1163WC0200XCritical Care Medicine Registered Nurse201390291RNOR
2363LF0000XFamily Nurse Practitioner202000541NP-PPOR

General Provider Information

NPI Number : 1598309387
Entity Type Code : Individual
Provider Name (Legal Business Name) : KELLY EILEEN CHURCH FNP
Provider Business Mailing Address
First Line : 931 CHEVY WAY
Second Line :
City : MEDFORD
State : OR
Zip : 97504-4127
Country : US
Telephone Number : 541-690-3555
Fax Number :
Provider Business Practice Location Address
First Line : 910 S CENTRAL AVE
Second Line :
City : MEDFORD
State : OR
Zip : 97501-7822
Country : US
Telephone Number : 541-618-1380
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/05/2019
Last Update Date : 07/02/2020

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