Provider Demographics
NPI:1013674605
Name:KELLY, KATRINA NICOLE (CNM)
Entity Type:Individual
Prefix:MRS
First Name:KATRINA
Middle Name:NICOLE
Last Name:KELLY
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
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Mailing Address - Street 1:350 W COUNTRY CLUB RD STE 203
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5221
Mailing Address - Country:US
Mailing Address - Phone:575-624-4646
Mailing Address - Fax:575-625-8498
Practice Address - Street 1:350 W COUNTRY CLUB RD STE 203
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5221
Practice Address - Country:US
Practice Address - Phone:575-624-4646
Practice Address - Fax:575-625-8498
Is Sole Proprietor?:No
Enumeration Date:2021-11-18
Last Update Date:2022-03-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NM811367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife