Provider Demographics
NPI:1366156226
Name:MCKIM, KELLI L
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:L
Last Name:MCKIM
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 1:651 COLLIERS WAY STE 401
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-5054
Mailing Address - Country:US
Mailing Address - Phone:304-908-4617
Mailing Address - Fax:
Practice Address - Street 1:651 COLLIERS WAY STE 401
Practice Address - Street 2:
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062-5054
Practice Address - Country:US
Practice Address - Phone:304-908-4617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-05
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV115106363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner