Provider Demographics
NPI:1508555210
Name:MOTHERSEAD, KELSIE
Entity Type:Individual
Prefix:
First Name:KELSIE
Middle Name:
Last Name:MOTHERSEAD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 GATEWAY BLVD N
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-9658
Mailing Address - Country:US
Mailing Address - Phone:219-921-1444
Mailing Address - Fax:
Practice Address - Street 1:601 GATEWAY BLVD N
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-9658
Practice Address - Country:US
Practice Address - Phone:219-921-1444
Practice Address - Fax:219-921-5303
Is Sole Proprietor?:No
Enumeration Date:2023-05-08
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant