Provider Demographics
NPI:1245751056
Name:BETZ, KELLY (APRN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BETZ
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-588-4710
Mailing Address - Fax:502-588-4771
Practice Address - Street 1:8033 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40258-1344
Practice Address - Country:US
Practice Address - Phone:502-899-6150
Practice Address - Fax:502-891-6368
Is Sole Proprietor?:No
Enumeration Date:2017-06-30
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3011450363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
F06172199OtherAANP CERTIFICATION NUMBER