Provider Demographics
NPI:1881900058
Name:DERGANC, KELLY MARIE (ARNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:DERGANC
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 SW MULVANE ST
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66606-1677
Mailing Address - Country:US
Mailing Address - Phone:785-357-0301
Mailing Address - Fax:785-357-6589
Practice Address - Street 1:100 MERCY WAY
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-4524
Practice Address - Country:US
Practice Address - Phone:417-556-2727
Practice Address - Fax:785-357-6589
Is Sole Proprietor?:No
Enumeration Date:2010-08-26
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS141458363LA2200X
MO2012035666363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS068002116OtherMEDICARE PTAN
KS200674390BMedicaid