Provider Demographics
NPI:1275730574
Name:PELOSI-KELLY, JANE M (ANP-BC)
Entity Type:Individual
Prefix:MRS
First Name:JANE
Middle Name:M
Last Name:PELOSI-KELLY
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4405 WEAVER PKWY
Mailing Address - Street 2:
Mailing Address - City:WARRENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60555-3269
Mailing Address - Country:US
Mailing Address - Phone:630-933-4847
Mailing Address - Fax:630-933-4558
Practice Address - Street 1:4405 WEAVER PKWY
Practice Address - Street 2:
Practice Address - City:WARRENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60555-3269
Practice Address - Country:US
Practice Address - Phone:630-933-4847
Practice Address - Fax:630-933-4558
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209004060363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT01883OtherMEDICARE (INDIVIDUAL)
IL206147OtherMEDICARE RAILROAD (GROUP)
ILCA4748OtherMEDICARE RAILROAD (GROUP)
ILP01013429OtherMEDICARE RAILROAD (INDIVIDUAL)
IL$$$$$$$$$001Medicaid