Provider Demographics
NPI:1962462689
Name:BOYER, KELLY JO (NP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JO
Last Name:BOYER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1004 PARKWAY AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516-9326
Mailing Address - Country:US
Mailing Address - Phone:574-294-1883
Mailing Address - Fax:574-295-1749
Practice Address - Street 1:1004 PARKWAY AVE
Practice Address - Street 2:SUITE C
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-9326
Practice Address - Country:US
Practice Address - Phone:574-294-1883
Practice Address - Fax:574-295-1749
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2015-02-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN71001272A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200313030Medicaid
IN200313030Medicaid