Provider Demographics
NPI:1184668063
Name:KELSEY, MARY LOU (ANP CNM RN)
Entity Type:Individual
Prefix:
First Name:MARY LOU
Middle Name:
Last Name:KELSEY
Suffix:
Gender:F
Credentials:ANP CNM RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4136 BARTLETT ST
Mailing Address - Street 2:HOMER MEDICAL CLINIC
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603
Mailing Address - Country:US
Mailing Address - Phone:907-235-8586
Mailing Address - Fax:907-235-6639
Practice Address - Street 1:4136 BARTLETT ST
Practice Address - Street 2:HOMER MEDICAL CLINIC
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603
Practice Address - Country:US
Practice Address - Phone:907-235-8586
Practice Address - Fax:907-235-6639
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKRN8404163W00000X
AKNP47367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MK0010164OtherUSDA
AKNM0188Medicaid
AKK151574Medicare ID - Type Unspecified
AKNM0188Medicaid