Provider Demographics
NPI:1841357076
Name:KING, KELLI A L (APRN)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:A L
Last Name:KING
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:A
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:1021 S COTTONWOOD ST
Mailing Address - Street 2:
Mailing Address - City:NORTH PLATTE
Mailing Address - State:NE
Mailing Address - Zip Code:69101-6138
Mailing Address - Country:US
Mailing Address - Phone:308-534-4438
Mailing Address - Fax:308-534-4190
Practice Address - Street 1:1021 S COTTONWOOD ST
Practice Address - Street 2:
Practice Address - City:NORTH PLATTE
Practice Address - State:NE
Practice Address - Zip Code:69101-6138
Practice Address - Country:US
Practice Address - Phone:308-534-4438
Practice Address - Fax:308-534-4190
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE110673363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NEDV8242OtherMEDICARE RR FOR BUSINESS
NE100264810-00Medicaid
NEP01500120OtherMEDICARE RR FOR KELLI
38966OtherBCBS PROVIDER#
NEDV8242OtherMEDICARE RR FOR BUSINESS