MEDICARE: DR. TRACE KELLY FNP-C, DC

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	111NR0400X	Rehabilitation Chiropractor	4973	KY
2	363LF0000X	Family Nurse Practitioner	3015925	KY

General Provider Information

NPI Number	:	1629296603
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TRACE KELLY FNP-C, DC

Provider Business Mailing Address
First Line	:	4227 POPLAR LEVEL RD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40213-1527
Country	:	US
Telephone Number	:	502-451-5959
Fax Number	:

Provider Business Practice Location Address
First Line	:	4613 ROXANN BLVD STE 101
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40218-4072
Country	:	US
Telephone Number	:	502-415-3943
Fax Number	:	502-451-5041

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

Provider Enumeration Date	:	04/23/2007
Last Update Date	:	07/07/2021

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