Provider Demographics
NPI:1306309117
Name:KELLEY, VIVIENNE M (CNP)
Entity type:Individual
Prefix:
First Name:VIVIENNE
Middle Name:M
Last Name:KELLEY
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 S DIAMOND AVE
Mailing Address - Street 2:
Mailing Address - City:DEMING
Mailing Address - State:NM
Mailing Address - Zip Code:88030-3752
Mailing Address - Country:US
Mailing Address - Phone:575-546-4336
Mailing Address - Fax:
Practice Address - Street 1:500 W FORT ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4501
Practice Address - Country:US
Practice Address - Phone:208-422-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-09
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM56876363LF0000X
TXAP140458363LF0000X
ID72817363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily