Provider Demographics
NPI:1518488634
Name:KELLY, SAMANTHA (FNP-C)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4036 RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-1720
Mailing Address - Country:US
Mailing Address - Phone:719-251-1594
Mailing Address - Fax:514-236-8737
Practice Address - Street 1:4036 RIDGE DR
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1720
Practice Address - Country:US
Practice Address - Phone:719-251-1594
Practice Address - Fax:514-236-8737
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-28
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95006818363LF0000X
COAPN.0995461-NP363LF0000X
CA95034970163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse