Provider Demographics
NPI:1710530605
Name:HOUSE, KELSEY
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:HOUSE
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 1:1201 MICHIGAN AVE STE 270
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-1530
Mailing Address - Country:US
Mailing Address - Phone:574-722-4927
Mailing Address - Fax:574-732-0520
Practice Address - Street 1:1201 MICHIGAN AVE STE 270
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-1530
Practice Address - Country:US
Practice Address - Phone:574-722-4927
Practice Address - Fax:574-732-0520
Is Sole Proprietor?:No
Enumeration Date:2019-07-19
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71009319A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily