Provider Demographics
NPI:1255611059
Name:PAVLISH, KELLI R (NP)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:R
Last Name:PAVLISH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:RAE
Other - Last Name:JIROVSKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12717 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:NE
Mailing Address - Zip Code:68123-3232
Mailing Address - Country:US
Mailing Address - Phone:402-292-6006
Mailing Address - Fax:402-292-7465
Practice Address - Street 1:1320 GALVIN RD S
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:NE
Practice Address - Zip Code:68005-3064
Practice Address - Country:US
Practice Address - Phone:402-292-6006
Practice Address - Fax:402-292-7465
Is Sole Proprietor?:No
Enumeration Date:2011-08-24
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE11265363L00000X
NE111264363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health