Provider Demographics
NPI:1467958975
Name:PARKER, KELLIE R (NP)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:R
Last Name:PARKER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:R
Other - Last Name:SWAFFORD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2518 E DUPONT RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1675
Mailing Address - Country:US
Mailing Address - Phone:260-432-4400
Mailing Address - Fax:260-969-6898
Practice Address - Street 1:1275 PROVIDENT DR
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-3265
Practice Address - Country:US
Practice Address - Phone:574-269-4026
Practice Address - Fax:574-269-7444
Is Sole Proprietor?:No
Enumeration Date:2018-04-03
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71007937A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily