Provider Demographics
NPI:1841660792
Name:WILKENS, KELLY ANN (AGNP)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANN
Last Name:WILKENS
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:POPE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12700 SOUTHFORK RD
Mailing Address - Street 2:STE 200
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-3201
Mailing Address - Country:US
Mailing Address - Phone:314-543-5942
Mailing Address - Fax:314-543-5947
Practice Address - Street 1:12700 SOUTHFORK RD
Practice Address - Street 2:STE 200
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-3201
Practice Address - Country:US
Practice Address - Phone:314-543-5942
Practice Address - Fax:314-543-5947
Is Sole Proprietor?:No
Enumeration Date:2015-10-05
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015024611363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner