Provider Demographics
NPI:1467853424
Name:DOLL, KELLI SUE (APRN)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:SUE
Last Name:DOLL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:SUE
Other - Last Name:THIESEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:16901 LAKESIDE HILLS CT
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68130-2318
Mailing Address - Country:US
Mailing Address - Phone:855-524-4001
Mailing Address - Fax:402-717-7340
Practice Address - Street 1:16901 LAKESIDE HILLS CT
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68130-2318
Practice Address - Country:US
Practice Address - Phone:855-524-4001
Practice Address - Fax:402-717-7340
Is Sole Proprietor?:No
Enumeration Date:2014-09-09
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE111712363LF0000X, 363L00000X
IAA138823363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1467853424Medicaid
NE47037660412Medicaid
IA1467853424Medicaid