Provider Demographics
NPI:1033153804
Name:KELLEY, WANDA ELAINE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:WANDA
Middle Name:ELAINE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:2708 HIGH PLAINS CT
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-6501
Mailing Address - Country:US
Mailing Address - Phone:970-223-6753
Mailing Address - Fax:970-266-1302
Practice Address - Street 1:COLORADO STATE UNIVERSITY HARTSHORN HEALTH SERVICE
Practice Address - Street 2:8031 CAMPUS DELIVERY
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80523-0001
Practice Address - Country:US
Practice Address - Phone:970-491-7121
Practice Address - Fax:970-491-0268
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO63998163W00000X
CO109125-22363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily