Provider Demographics
NPI:1013288448
Name:LOSINIECKI, KELLY MAE (NP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MAE
Last Name:LOSINIECKI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:MAE
Other - Last Name:MCCARTHY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:211 N EDDY ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2808
Mailing Address - Country:US
Mailing Address - Phone:574-237-9231
Mailing Address - Fax:
Practice Address - Street 1:211 N EDDY ST.
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-3096
Practice Address - Country:US
Practice Address - Phone:574-237-9231
Practice Address - Fax:574-204-6355
Is Sole Proprietor?:No
Enumeration Date:2012-01-17
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71003885A363L00000X
IN28176558A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000758607OtherBCBS BMG NORTH CENTRAL NEUROSURGERY
INP01203728OtherRR MEDICARE
IN201058080Medicaid
IN000000758607OtherBCBS BMG NORTH CENTRAL NEUROSURGERY