Provider Demographics
NPI:1659315315
Name:KELLY, KATHERINE MONICA (RN/NP)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:MONICA
Last Name:KELLY
Suffix:
Gender:F
Credentials:RN/NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-4208
Mailing Address - Country:US
Mailing Address - Phone:765-973-9294
Mailing Address - Fax:812-375-3477
Practice Address - Street 1:2400 17TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-5351
Practice Address - Country:US
Practice Address - Phone:812-376-5016
Practice Address - Fax:812-376-5928
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28122181A163WP0807X
IN71000702A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200165720Medicaid
IN200165720AMedicaid
IN798900FFMedicare PIN