Provider Demographics
NPI:1508991902
Name:TRIEGLAFF, KELLY JO (NP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:JO
Last Name:TRIEGLAFF
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 1:12110 WEIGELA CT
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46814-4536
Mailing Address - Country:US
Mailing Address - Phone:260-672-3094
Mailing Address - Fax:260-672-0573
Practice Address - Street 1:530 GUILFORD ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:IN
Practice Address - Zip Code:46750-2708
Practice Address - Country:US
Practice Address - Phone:260-355-0722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000268A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily