Provider Demographics
NPI:1164073557
Name:WAKEFIELD, KELLY (APRNCNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WAKEFIELD
Suffix:
Gender:F
Credentials:APRNCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46806-1100
Mailing Address - Country:US
Mailing Address - Phone:260-702-4404
Mailing Address - Fax:260-744-3006
Practice Address - Street 1:2700 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46806-1100
Practice Address - Country:US
Practice Address - Phone:260-702-4404
Practice Address - Fax:260-744-3006
Is Sole Proprietor?:No
Enumeration Date:2019-09-26
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71009784A363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health