Provider Demographics
NPI:1205117058
Name:DODDS, KELLY JEAN (ANP)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:JEAN
Last Name:DODDS
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:314-747-5838
Mailing Address - Fax:314-362-5969
Practice Address - Street 1:4921 PARKVIEW PL
Practice Address - Street 2:DIV IM HOSPITALIST MEDSTE 8C
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1032
Practice Address - Country:US
Practice Address - Phone:314-747-5838
Practice Address - Fax:314-362-5969
Is Sole Proprietor?:No
Enumeration Date:2011-09-07
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011037546363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO427116009Medicaid