Provider Demographics
NPI:1801963715
Name:RANEY, KELLY K (RN, FNP, CS)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:K
Last Name:RANEY
Suffix:
Gender:F
Credentials:RN, FNP, CS
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Other - First Name:
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Mailing Address - Street 1:1165 N BUTTERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-1056
Mailing Address - Country:US
Mailing Address - Phone:417-777-8131
Mailing Address - Fax:417-777-8892
Practice Address - Street 1:12639 OLD TESSON RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2786
Practice Address - Country:US
Practice Address - Phone:314-849-0311
Practice Address - Fax:314-849-4423
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2011-10-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO099454363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO427759113Medicaid
MO836093424Medicare PIN