Provider Demographics
NPI:1346587706
Name:JEFFERY, KELLY R (RN, MSN, FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:R
Last Name:JEFFERY
Suffix:
Gender:F
Credentials:RN, MSN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11
Mailing Address - Street 2:
Mailing Address - City:MOUNT CARBON
Mailing Address - State:WV
Mailing Address - Zip Code:25139-0011
Mailing Address - Country:US
Mailing Address - Phone:304-767-8145
Mailing Address - Fax:
Practice Address - Street 1:4605 MACCORKLE AVE SW
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1311
Practice Address - Country:US
Practice Address - Phone:304-414-4800
Practice Address - Fax:304-414-4801
Is Sole Proprietor?:No
Enumeration Date:2013-01-05
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV68371363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1346587706Medicaid
WVWV2723B441Medicare PIN
WVB441OtherGROUP MEDICARE
WVWV2723B441Medicare PIN