Provider Demographics
NPI:1780699132
Name:HASENAUER, KELLEY ANNE (APRN)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:ANNE
Last Name:HASENAUER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 W REID AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:NORTH PLATTE
Mailing Address - State:NE
Mailing Address - Zip Code:69101-6583
Mailing Address - Country:US
Mailing Address - Phone:308-534-0090
Mailing Address - Fax:308-534-0091
Practice Address - Street 1:810 W REID AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:NORTH PLATTE
Practice Address - State:NE
Practice Address - Zip Code:69101-6583
Practice Address - Country:US
Practice Address - Phone:308-534-0090
Practice Address - Fax:308-534-0091
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE110460363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE37425OtherBCBS PROVIDER NUMBER
P36359Medicare UPIN
NE277380Medicare ID - Type Unspecified