Provider Demographics
NPI:1912203894
Name:BURRESS, KELLI M (NP)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:M
Last Name:BURRESS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:M
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1100 SOUTHFIELD DR STE 1370
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46168-4300
Mailing Address - Country:US
Mailing Address - Phone:317-837-5566
Mailing Address - Fax:317-837-5580
Practice Address - Street 1:1152 E US HIGHWAY 36
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE
Practice Address - State:IN
Practice Address - Zip Code:46105-9604
Practice Address - Country:US
Practice Address - Phone:765-522-1889
Practice Address - Fax:765-522-3583
Is Sole Proprietor?:No
Enumeration Date:2011-02-10
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71003520A363LF0000X
IN71003520363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201019020Medicaid
INP01141623Medicare PIN
INM400059690Medicare PIN
M400045870Medicare PIN
INM400058699Medicare PIN