Provider Demographics
NPI:1497091888
Name:BELLEVUE PRIMARY HEALTHCARE PC
Entity Type:Organization
Organization Name:BELLEVUE PRIMARY HEALTHCARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:PAVLISH
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:402-525-6976
Mailing Address - Street 1:703 CANYON RD
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:NE
Mailing Address - Zip Code:68005-2735
Mailing Address - Country:US
Mailing Address - Phone:402-525-6976
Mailing Address - Fax:
Practice Address - Street 1:12717 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:NE
Practice Address - Zip Code:68123-3232
Practice Address - Country:US
Practice Address - Phone:402-525-6976
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-12
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
NE111265261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care