Provider Demographics
NPI:1497293526
Name:WELLER, KEVIN (APRN)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:WELLER
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PORTSMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:STRATHAM
Mailing Address - State:NH
Mailing Address - Zip Code:03885-2585
Mailing Address - Country:US
Mailing Address - Phone:603-772-3600
Mailing Address - Fax:
Practice Address - Street 1:1 PORTSMOUTH AVE
Practice Address - Street 2:
Practice Address - City:STRATHAM
Practice Address - State:NH
Practice Address - Zip Code:03885-2585
Practice Address - Country:US
Practice Address - Phone:603-772-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-09
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH064926-23363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner