Provider Demographics
NPI:1285060947
Name:DUNKIN, KELLIE LYN (MSN NP)
Entity type:Individual
Prefix:MS
First Name:KELLIE
Middle Name:LYN
Last Name:DUNKIN
Suffix:
Gender:F
Credentials:MSN NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:451 S PARK RIDGE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-8589
Mailing Address - Country:US
Mailing Address - Phone:812-331-8282
Mailing Address - Fax:812-331-8283
Practice Address - Street 1:451 S PARK RIDGE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-8589
Practice Address - Country:US
Practice Address - Phone:812-331-8282
Practice Address - Fax:812-331-8283
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-25
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28140084A261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care