Provider Demographics
NPI:1669292868
Name:ANDERSON, KELSEY NICOLE (PA)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:NICOLE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3909 W 141ST DR
Mailing Address - Street 2:
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66224-9714
Mailing Address - Country:US
Mailing Address - Phone:913-522-5670
Mailing Address - Fax:
Practice Address - Street 1:1318 KANSAS DR
Practice Address - Street 2:
Practice Address - City:PAOLA
Practice Address - State:KS
Practice Address - Zip Code:66071-2107
Practice Address - Country:US
Practice Address - Phone:913-557-5678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-12
Last Update Date:2024-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-02998363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical