Provider Demographics
NPI:1740821453
Name:CREASER, KELLIE MARIE (FNP, PMHNP)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:MARIE
Last Name:CREASER
Suffix:
Gender:F
Credentials:FNP, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 HASSETT ST
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97415-7201
Mailing Address - Country:US
Mailing Address - Phone:307-351-3666
Mailing Address - Fax:
Practice Address - Street 1:840 HASSETT ST
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415-7201
Practice Address - Country:US
Practice Address - Phone:307-351-3666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-03
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201908534NP-PP363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500771078Medicaid
OR1083656367OtherCURRY MEDICAL CENTER NPI