Provider Demographics
NPI:1073996021
Name:PIRRUCCELLO, KELLI L (RN)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:L
Last Name:PIRRUCCELLO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:L
Other - Last Name:CRAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2797
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-2797
Mailing Address - Country:US
Mailing Address - Phone:402-354-4230
Mailing Address - Fax:402-354-6171
Practice Address - Street 1:707 N 190TH PLZ
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:NE
Practice Address - Zip Code:68022-3974
Practice Address - Country:US
Practice Address - Phone:402-815-6428
Practice Address - Fax:402-815-1565
Is Sole Proprietor?:No
Enumeration Date:2015-07-08
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE71216163W00000X
NE111868363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE100258661-00Medicaid
IA1073996021Medicaid
NE096573074Medicare PIN