Provider Demographics
NPI:1255920526
Name:KELLY, STEPHANIE SUZANNE (RN)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:SUZANNE
Last Name:KELLY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 OLD SOUTH RIVER RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-4120
Mailing Address - Country:US
Mailing Address - Phone:636-224-1210
Mailing Address - Fax:636-246-1008
Practice Address - Street 1:4066 DUNNICA AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63116-3510
Practice Address - Country:US
Practice Address - Phone:636-224-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001022438163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse