Provider Demographics
NPI:1619221819
Name:BALL, KELLY LYNNE (WHNP)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:LYNNE
Last Name:BALL
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-362-3181
Mailing Address - Fax:314-362-2893
Practice Address - Street 1:3023 N BALLAS RD
Practice Address - Street 2:DIV OBGYN GYNECOLOGIC ONCOLOGY, STE 450D
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2330
Practice Address - Country:US
Practice Address - Phone:314-362-3181
Practice Address - Fax:314-362-2893
Is Sole Proprietor?:No
Enumeration Date:2012-11-09
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012036148363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420042260Medicaid