Provider Demographics
NPI:1740968080
Name:KELLY, SAMANTHA JAYNE (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:JAYNE
Last Name:KELLY
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 1:31963 HWY AD
Mailing Address - Street 2:
Mailing Address - City:COLE CAMP
Mailing Address - State:MO
Mailing Address - Zip Code:65325-2823
Mailing Address - Country:US
Mailing Address - Phone:660-281-1006
Mailing Address - Fax:
Practice Address - Street 1:302 US-65
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:MO
Practice Address - Zip Code:65338-2012
Practice Address - Country:US
Practice Address - Phone:660-547-3915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-07
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023027198363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily