Provider Demographics
NPI:1326597683
Name:KELLEY, MARIA (NP)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:
Other - Last Name:JOHLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2121 E HARMONY RD UNIT 100
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-3401
Mailing Address - Country:US
Mailing Address - Phone:970-221-1000
Mailing Address - Fax:970-297-6844
Practice Address - Street 1:2121 E HARMONY RD UNIT 100
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-3401
Practice Address - Country:US
Practice Address - Phone:970-221-1000
Practice Address - Fax:970-297-6844
Is Sole Proprietor?:No
Enumeration Date:2016-09-28
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0992709-NP363LF0000X, 363LG0600X
CO0198115163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPENDINGMedicaid
COPENDINGMedicaid