Provider Demographics
NPI:1114268182
Name:KELLY, PATTI SUE (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:PATTI
Middle Name:SUE
Last Name:KELLY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:PATTI
Other - Middle Name:SUE
Other - Last Name:BOOTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3600 30TH ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50310-5753
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3600 30TH ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50310-5753
Practice Address - Country:US
Practice Address - Phone:515-699-5999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-15
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA081578163W00000X, 163WC0400X, 163WP0200X
IAA081578363LF0000X, 363LP2300X, 363LX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational Health
No163W00000XNursing Service ProvidersRegistered Nurse
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care