Provider Demographics
NPI:1720216906
Name:ANDERSON, KELLIE COPLIN (CRNP)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:COPLIN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2705
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35804-2705
Mailing Address - Country:US
Mailing Address - Phone:256-265-1775
Mailing Address - Fax:256-265-1780
Practice Address - Street 1:401 LOWELL DR SE STE 5
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801
Practice Address - Country:US
Practice Address - Phone:256-265-1775
Practice Address - Fax:256-265-1780
Is Sole Proprietor?:No
Enumeration Date:2009-06-26
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-083086363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL199998Medicaid