Provider Demographics
NPI:1932876455
Name:GILLIAM, KELSEY
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:
Other - Last Name:WEBBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9350 E 35TH ST N STE 101
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-2022
Mailing Address - Country:US
Mailing Address - Phone:316-265-1308
Mailing Address - Fax:316-265-4480
Practice Address - Street 1:9350 E 35TH ST N STE 101
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-2022
Practice Address - Country:US
Practice Address - Phone:316-165-1308
Practice Address - Fax:316-265-4480
Is Sole Proprietor?:No
Enumeration Date:2021-08-23
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-80534363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily