Provider Demographics
NPI:1609863786
Name:KIESLER, KELLEY R (APRN)
Entity Type:Individual
Prefix:MS
First Name:KELLEY
Middle Name:R
Last Name:KIESLER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 950248
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0248
Mailing Address - Country:US
Mailing Address - Phone:502-489-5730
Mailing Address - Fax:502-489-5753
Practice Address - Street 1:3900 KRESGE WAY STE 51
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4683
Practice Address - Country:US
Practice Address - Phone:502-259-5955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001828A363L00000X
KY3004367363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP00263361OtherRR MCR
IN200499170Medicaid
KY78013224Medicaid
Q27816Medicare UPIN
KYP00263361OtherRR MCR
IN122620PMedicare ID - Type Unspecified