Provider Demographics
NPI:1346415718
Name:KELL, TIMOTHY BRENT (NP)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:BRENT
Last Name:KELL
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 S NEW BALLAS RD STE 228A
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8256
Mailing Address - Country:US
Mailing Address - Phone:314-251-4966
Mailing Address - Fax:
Practice Address - Street 1:621 S NEW BALLAS RD STE 228A
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8256
Practice Address - Country:US
Practice Address - Phone:314-251-4966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-28
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000151380363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00995895OtherRAILROAD MEDICARE
MO1346415718Medicaid
MOP00995895OtherRAILROAD MEDICARE