Provider Demographics
NPI:1619071206
Name:THELEN, KELLY LYNN (APRN)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:LYNN
Last Name:THELEN
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 1:5930 S 58TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-6402
Mailing Address - Country:US
Mailing Address - Phone:402-483-0431
Mailing Address - Fax:402-483-9905
Practice Address - Street 1:3540 VILLAGE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-4706
Practice Address - Country:US
Practice Address - Phone:402-420-7113
Practice Address - Fax:402-328-8314
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE110335363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE37662OtherBCBS
NE10025777400Medicaid
NE47381OtherBCBS
NE099827003Medicare PIN
NE47381OtherBCBS
NEP00902994Medicare PIN
NENA1403003Medicare PIN