Provider Demographics
NPI:1235460957
Name:CARRICO-WELCH, KELLEY (ARNP)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:CARRICO-WELCH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11969 S DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:KY
Mailing Address - Zip Code:42776-9739
Mailing Address - Country:US
Mailing Address - Phone:270-369-9706
Mailing Address - Fax:270-369-9263
Practice Address - Street 1:11969 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:KY
Practice Address - Zip Code:42776-9739
Practice Address - Country:US
Practice Address - Phone:270-369-9706
Practice Address - Fax:270-369-9263
Is Sole Proprietor?:No
Enumeration Date:2010-01-20
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6300P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0611211Medicare PIN
KY00011045Medicare PIN
KY0745404Medicare PIN
KY0745304Medicare PIN