Provider Demographics
NPI:1356959944
Name:KELLY, JENNIFER LYNNE (AGNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNNE
Last Name:KELLY
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 CORONA RD STE 102
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-2582
Mailing Address - Country:US
Mailing Address - Phone:573-234-1800
Mailing Address - Fax:
Practice Address - Street 1:2101 CORONA RD STE 102
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-2582
Practice Address - Country:US
Practice Address - Phone:573-234-1800
Practice Address - Fax:573-234-1799
Is Sole Proprietor?:No
Enumeration Date:2020-07-20
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009019364163W00000X
MO2020003607363LF0000X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily