Provider Demographics
NPI:1700039781
Name:JARCZYK, KELLY (ARNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:JARCZYK
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22700 W 55TH TER
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SHAWNEE
Mailing Address - State:KS
Mailing Address - Zip Code:66226-5602
Mailing Address - Country:US
Mailing Address - Phone:612-225-1534
Mailing Address - Fax:
Practice Address - Street 1:225700 W 55TH TERR
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:KS
Practice Address - Zip Code:66226-0000
Practice Address - Country:US
Practice Address - Phone:612-225-1534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-04
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS46294363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSKA1087017Medicare PIN