Provider Demographics
NPI:1205094000
Name:KELLY, KESHA RAE (NP)
Entity type:Individual
Prefix:
First Name:KESHA
Middle Name:RAE
Last Name:KELLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8091 TOWNSHIP LINE RD STE 206
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-2495
Mailing Address - Country:US
Mailing Address - Phone:317-415-1000
Mailing Address - Fax:317-415-1010
Practice Address - Street 1:8091 TOWNSHIP LINE RD STE 206
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2495
Practice Address - Country:US
Practice Address - Phone:317-415-1000
Practice Address - Fax:317-415-1010
Is Sole Proprietor?:No
Enumeration Date:2008-05-28
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001948A363LX0001X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200540450Medicaid
INM400067907Medicare PIN