Provider Demographics
NPI:1710577440
Name:KELLEY, WILLIAM ERIC (FNP)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:ERIC
Last Name:KELLEY
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:578 LOST CIR APT D
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-4029
Mailing Address - Country:US
Mailing Address - Phone:270-303-2499
Mailing Address - Fax:
Practice Address - Street 1:578 LOST CIR APT D
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-4029
Practice Address - Country:US
Practice Address - Phone:270-303-2499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-26
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3016630363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily