Provider Demographics
NPI:1477549665
Name:ARNOLD, KELLI L (NP)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:L
Last Name:ARNOLD
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 1:9301 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-7745
Mailing Address - Country:US
Mailing Address - Phone:219-662-5065
Mailing Address - Fax:
Practice Address - Street 1:9301 MADISON ST
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-7745
Practice Address - Country:US
Practice Address - Phone:219-662-5065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28126405A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200290230Medicaid
IN170680CCMedicare ID - Type Unspecified
IN200290230Medicaid