Provider Demographics
NPI:1417266958
Name:VANBUSSUM, KELLY S (NP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:S
Last Name:VANBUSSUM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 BLUEGRASS AVE STE 4TH
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40215-1161
Mailing Address - Country:US
Mailing Address - Phone:502-367-3360
Mailing Address - Fax:502-367-3365
Practice Address - Street 1:1850 BLUEGRASS AVE STE 4TH
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-1161
Practice Address - Country:US
Practice Address - Phone:502-367-3360
Practice Address - Fax:502-367-3365
Is Sole Proprietor?:No
Enumeration Date:2010-10-01
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6647P363L00000X
KY3006647363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100149050Medicaid