Provider Demographics
NPI:1821552464
Name:KELLY, MAHARI (APRN)
Entity Type:Individual
Prefix:
First Name:MAHARI
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2811 W 91ST ST
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-1339
Mailing Address - Country:US
Mailing Address - Phone:773-206-4466
Mailing Address - Fax:
Practice Address - Street 1:818 S WOLCOTT AVE STE 802
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3702
Practice Address - Country:US
Practice Address - Phone:312-996-4656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209018700363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily