Provider Demographics
NPI:1750062410
Name:KELLY, KATHERINE JOANN (NP)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:JOANN
Last Name:KELLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:J
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5165 MCCARTY LN
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-8764
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-26
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71014151A363LA2100X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300081318Medicaid
IN1103705118OtherANTHEM PTAN
INQ00651574OtherRAILROAD PTAN