Provider Demographics
NPI:1083079776
Name:CHRISMAN, KELLY (NPC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:CHRISMAN
Suffix:
Gender:F
Credentials:NPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30566 LUNAR DR
Mailing Address - Street 2:
Mailing Address - City:MARCELINE
Mailing Address - State:MO
Mailing Address - Zip Code:64658-1840
Mailing Address - Country:US
Mailing Address - Phone:660-591-6217
Mailing Address - Fax:
Practice Address - Street 1:3151 LITTON RD
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:MO
Practice Address - Zip Code:64601-8502
Practice Address - Country:US
Practice Address - Phone:660-646-4032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-22
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015043928363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner