Provider Demographics
NPI:1316290646
Name:KELLY, KATHERINE (FNP-C)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:
Other - Last Name:LARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 200149
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99520-0149
Mailing Address - Country:US
Mailing Address - Phone:907-561-2211
Mailing Address - Fax:
Practice Address - Street 1:3841 PIPER ST STE T100
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508
Practice Address - Country:US
Practice Address - Phone:907-561-3211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-24
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK125191363L00000X
NCF0612510363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner