Provider Demographics
NPI:1588852107
Name:KELLEY, PAMELA SUE (CNP)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:SUE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:SUE
Other - Last Name:POWERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 19248
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9248
Mailing Address - Country:US
Mailing Address - Phone:217-528-7541
Mailing Address - Fax:217-525-7616
Practice Address - Street 1:747 N RUTLEDGE ST
Practice Address - Street 2:BAYLIS BUILDING, 2ND FLOOR
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-6700
Practice Address - Country:US
Practice Address - Phone:217-757-7932
Practice Address - Fax:217-757-7920
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209003154363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041321588OtherRN LICENSE