Provider Demographics
NPI:1801369434
Name:ANDERSON, KELLY ANN (APRN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:APRN
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 745
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67201-0745
Mailing Address - Country:US
Mailing Address - Phone:316-440-2565
Mailing Address - Fax:316-440-2750
Practice Address - Street 1:4722 W KELLOGG DR
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67209-2508
Practice Address - Country:US
Practice Address - Phone:316-440-2565
Practice Address - Fax:316-440-2750
Is Sole Proprietor?:No
Enumeration Date:2019-01-07
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS78496363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily