Provider Demographics
NPI:1437526894
Name:LANDRUM, KELLI S (FNP-C)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:S
Last Name:LANDRUM
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:S
Other - Last Name:VICEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:PO BOX 2949
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-2949
Mailing Address - Country:US
Mailing Address - Phone:907-260-7303
Mailing Address - Fax:907-260-7301
Practice Address - Street 1:805 FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:KENAI
Practice Address - State:AK
Practice Address - Zip Code:99611
Practice Address - Country:US
Practice Address - Phone:907-283-3600
Practice Address - Fax:907-283-3601
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-01
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA227339363L00000X
OR201506440NP-PP363LF0000X
AK133545363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1684877Medicaid