Provider Demographics
NPI:1134192925
Name:KELLAM-UPTON, MARY REBECCA (MSN FNP)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:REBECCA
Last Name:KELLAM-UPTON
Suffix:
Gender:F
Credentials:MSN FNP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:REBECCA
Other - Last Name:KELLAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2316 E MEYER BLVD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64132-1136
Mailing Address - Country:US
Mailing Address - Phone:816-276-4700
Mailing Address - Fax:816-276-3810
Practice Address - Street 1:2316 E MEYER BLVD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64132-1136
Practice Address - Country:US
Practice Address - Phone:816-276-4700
Practice Address - Fax:816-276-4700
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS45130363LF0000X
MO079829363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP22931Medicare UPIN