Provider Demographics
NPI:1629296603
Name:KELLY, TRACE (FNP-C, DC)
Entity Type:Individual
Prefix:DR
First Name:TRACE
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:FNP-C, DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4227 POPLAR LEVEL RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40213-1527
Mailing Address - Country:US
Mailing Address - Phone:502-451-5959
Mailing Address - Fax:
Practice Address - Street 1:4613 ROXANN BLVD STE 101
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-4072
Practice Address - Country:US
Practice Address - Phone:502-415-3943
Practice Address - Fax:502-451-5041
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4973111NR0400X
KY3015925363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No111NR0400XChiropractic ProvidersChiropractorRehabilitation