Provider Demographics
NPI:1780912550
Name:ST. JOHN, KELLY NICOLE (ACNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:NICOLE
Last Name:ST. JOHN
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:NICOLE
Other - Last Name:CARR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4315 DIPLOMACY DR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5926
Mailing Address - Country:US
Mailing Address - Phone:907-729-4750
Mailing Address - Fax:907-729-1831
Practice Address - Street 1:4315 DIPLOMACY DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5926
Practice Address - Country:US
Practice Address - Phone:907-729-4750
Practice Address - Fax:907-729-1831
Is Sole Proprietor?:No
Enumeration Date:2009-12-05
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1118363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care