Provider Demographics
NPI:1598073231
Name:MCSHANE, KELLY MARIE (NP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:MARIE
Last Name:MCSHANE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:MARIE
Other - Last Name:POSTMA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10420 BULL RUN DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-9109
Mailing Address - Country:US
Mailing Address - Phone:219-488-7781
Mailing Address - Fax:
Practice Address - Street 1:301 W HOMER ST
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-4358
Practice Address - Country:US
Practice Address - Phone:219-488-7781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-15
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28170048A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily