Provider Demographics
NPI:1285191817
Name:KELLEY, NICOLE (FNP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 N ROCKY CREEK RD
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-8836
Mailing Address - Country:US
Mailing Address - Phone:406-202-0313
Mailing Address - Fax:
Practice Address - Street 1:320 ALPENGLOW LN
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:MT
Practice Address - Zip Code:59047-8506
Practice Address - Country:US
Practice Address - Phone:406-222-3541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-01
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTNUR-APRN-LIC-147738363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner