Provider Demographics
NPI:1659054294
Name:GEMMILL, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GEMMILL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3076 PLAZA BLANCA
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-5342
Mailing Address - Country:US
Mailing Address - Phone:757-719-4550
Mailing Address - Fax:
Practice Address - Street 1:3160 AGUA FRIA ST
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-5402
Practice Address - Country:US
Practice Address - Phone:505-467-4605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-10
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001302317163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool