MEDICARE: DEAN M KELLY ANP

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	363LX0106X	Occupational Health Nurse Practitioner	71000948B	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000599883	OTHER	IN	ANTHEM
2	000000625966	OTHER	IN	ANTHEM

General Provider Information

NPI Number	:	1639209174
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEAN M KELLY ANP

Provider Business Mailing Address
First Line	:	760 PARK EAST BLVD STE 5
Second Line	:
City	:	LAFAYETTE
State	:	IN
Zip	:	47905-0796
Country	:	US
Telephone Number	:	765-447-7473
Fax Number	:	765-449-8504

Provider Business Practice Location Address
First Line	:	3218 DAUGHERTY DR STE 140
Second Line	:
City	:	LAFAYETTE
State	:	IN
Zip	:	47909-3997
Country	:	US
Telephone Number	:	765-502-4190
Fax Number	:	765-502-4191

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

Provider Enumeration Date	:	03/06/2007
Last Update Date	:	12/11/2019

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Directions to “ DEAN M KELLY ANP” Practice Location

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