Provider Demographics
NPI:1740865914
Name:KELLUM, STACY (FNP-C)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:KELLUM
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:ONEILL
Mailing Address - State:NE
Mailing Address - Zip Code:68763-1327
Mailing Address - Country:US
Mailing Address - Phone:402-540-1804
Mailing Address - Fax:
Practice Address - Street 1:527 N 5TH ST
Practice Address - Street 2:
Practice Address - City:ONEILL
Practice Address - State:NE
Practice Address - Zip Code:68763-1327
Practice Address - Country:US
Practice Address - Phone:402-540-1804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE113220363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily