Provider Demographics
NPI:1851047930
Name:KELTY, GWENDA (RN)
Entity Type:Individual
Prefix:
First Name:GWENDA
Middle Name:
Last Name:KELTY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6800 MOON CT
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47805-1277
Mailing Address - Country:US
Mailing Address - Phone:812-239-6713
Mailing Address - Fax:
Practice Address - Street 1:6800 MOON CT
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47805-1277
Practice Address - Country:US
Practice Address - Phone:812-239-6713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-26
Last Update Date:2022-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28123433A163WN0002X, 163WN0003X, 163WM0102X, 163WN1003X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care
No163WN0003XNursing Service ProvidersRegistered NurseNeonatal, Low-Risk
No163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn
No163WN1003XNursing Service ProvidersRegistered NurseNutrition Support