Provider Demographics
NPI:1053666792
Name:KELLEY, CHRISTY (NP)
Entity Type:Individual
Prefix:
First Name:CHRISTY
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19841 N IRIS LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-8832
Mailing Address - Country:US
Mailing Address - Phone:618-315-0153
Mailing Address - Fax:
Practice Address - Street 1:205 EAST HURON ST.
Practice Address - Street 2:
Practice Address - City:IRVINGTON
Practice Address - State:IL
Practice Address - Zip Code:62848
Practice Address - Country:US
Practice Address - Phone:618-249-6203
Practice Address - Fax:618-249-6263
Is Sole Proprietor?:No
Enumeration Date:2012-07-18
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009607363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily