Provider Demographics
NPI:1285184481
Name:BOVENKERK, KELLI JOY (NP)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:JOY
Last Name:BOVENKERK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:JOY
Other - Last Name:SENSMEIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3299
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89702-3299
Mailing Address - Country:US
Mailing Address - Phone:317-782-1577
Mailing Address - Fax:317-780-5538
Practice Address - Street 1:3834 S EMERSON AVE
Practice Address - Street 2:BUILDING C, SUITE 100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46203
Practice Address - Country:US
Practice Address - Phone:775-222-0044
Practice Address - Fax:888-700-0187
Is Sole Proprietor?:No
Enumeration Date:2016-10-12
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71006606A363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201398720Medicaid
IN201398720Medicaid