Provider Demographics
NPI:1790226744
Name:MAXWELL, KELLI
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:
Other - Last Name:PIERCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15604 PINEHURST DR STE 3
Mailing Address - Street 2:
Mailing Address - City:BASEHOR
Mailing Address - State:KS
Mailing Address - Zip Code:66007-8234
Mailing Address - Country:US
Mailing Address - Phone:913-342-8665
Mailing Address - Fax:
Practice Address - Street 1:15604 PINEHURST DR STE 3
Practice Address - Street 2:
Practice Address - City:BASEHOR
Practice Address - State:KS
Practice Address - Zip Code:66007-8234
Practice Address - Country:US
Practice Address - Phone:913-342-8665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-10
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS77637363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily