Provider Demographics
NPI:1710989132
Name:KELLEY, CHARLOTTE MARY (ARNP, GNP)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:MARY
Last Name:KELLEY
Suffix:
Gender:F
Credentials:ARNP, GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2213 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-5305
Mailing Address - Country:US
Mailing Address - Phone:515-237-3974
Mailing Address - Fax:515-883-2692
Practice Address - Street 1:2600 GRAND AVE
Practice Address - Street 2:SUITE 125
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50312-5375
Practice Address - Country:US
Practice Address - Phone:515-277-3400
Practice Address - Fax:515-277-9036
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00000363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
S49544Medicare UPIN