Provider Demographics
NPI:1881707453
Name:KELLY, KAY BOWIE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MRS
First Name:KAY
Middle Name:BOWIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1929 MASON DIXON HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:CORE
Mailing Address - State:WV
Mailing Address - Zip Code:26541
Mailing Address - Country:US
Mailing Address - Phone:304-879-5020
Mailing Address - Fax:304-879-4105
Practice Address - Street 1:1929 MASON DIXON HIGHWAY
Practice Address - Street 2:
Practice Address - City:CORE
Practice Address - State:WV
Practice Address - Zip Code:26541
Practice Address - Country:US
Practice Address - Phone:304-879-5020
Practice Address - Fax:304-879-4105
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV43007363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7101028000Medicaid
WVWV3681D142OtherMEDICARE PTAN
001722602OtherBLUE CROSS
WVP01268331OtherRAILROAD
WV571206Medicare UPIN
WV02602Medicare PIN