Provider Demographics
NPI:1184015323
Name:ROSANBALM, KELLIE ALICIA (APRN)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:ALICIA
Last Name:ROSANBALM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 COMMERCE CROSSING
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40229-2182
Mailing Address - Country:US
Mailing Address - Phone:502-253-4900
Mailing Address - Fax:502-489-5751
Practice Address - Street 1:793 EASTERN BYP STE 213
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-2440
Practice Address - Country:US
Practice Address - Phone:859-624-6501
Practice Address - Fax:859-624-6509
Is Sole Proprietor?:No
Enumeration Date:2015-02-10
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3009144363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100399020Medicaid
KYK196513Medicare PIN