Provider Demographics
NPI:1104240969
Name:HILLMER, KELLY LASHAWN
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:LASHAWN
Last Name:HILLMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 HEATHER RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-1523
Mailing Address - Country:US
Mailing Address - Phone:702-273-0301
Mailing Address - Fax:
Practice Address - Street 1:1309 HEATHER RIDGE RD
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-1523
Practice Address - Country:US
Practice Address - Phone:702-273-0301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-13
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV46-4790140171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor