Provider Demographics
NPI:1598824591
Name:WOOD, KELLERYN V (FNP)
Entity Type:Individual
Prefix:
First Name:KELLERYN
Middle Name:V
Last Name:WOOD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-6049
Mailing Address - Country:US
Mailing Address - Phone:207-828-1133
Mailing Address - Fax:207-828-8077
Practice Address - Street 1:800 MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-6049
Practice Address - Country:US
Practice Address - Phone:207-828-1133
Practice Address - Fax:207-828-8077
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME363L00000X363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME248410099Medicaid
ME248410099Medicaid
MENP130702Medicare PIN