Provider Demographics
NPI:1265499669
Name:SCHAAR-EVISTON, KELLI (ARNP)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:SCHAAR-EVISTON
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 1:2300 CHAMBER CENTER DRIVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FORT MITCHELL
Mailing Address - State:KY
Mailing Address - Zip Code:41017-1673
Mailing Address - Country:US
Mailing Address - Phone:859-344-5555
Mailing Address - Fax:859-655-4395
Practice Address - Street 1:5522 TAYLOR MILL RD
Practice Address - Street 2:
Practice Address - City:TAYLOR MILL
Practice Address - State:KY
Practice Address - Zip Code:41015-4604
Practice Address - Country:US
Practice Address - Phone:859-491-2855
Practice Address - Fax:859-655-4395
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1092435163W00000X
KY3003042363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78003936Medicaid
OH2498980Medicaid
KY0364952Medicare PIN
OH2498980Medicaid
KYP400036112Medicare PIN
KY78003936Medicaid