Provider Demographics
NPI:1386291177
Name:KELLY, KAILEE ANN
Entity type:Individual
Prefix:
First Name:KAILEE
Middle Name:ANN
Last Name:KELLY
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 1:2929 W LAKEFIELD DR
Mailing Address - Street 2:
Mailing Address - City:ALLIANCE
Mailing Address - State:NE
Mailing Address - Zip Code:69301-2032
Mailing Address - Country:US
Mailing Address - Phone:308-760-8129
Mailing Address - Fax:
Practice Address - Street 1:2091 BOX BUTTE AVE STE 700
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:NE
Practice Address - Zip Code:69301-4458
Practice Address - Country:US
Practice Address - Phone:308-762-7244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-26
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE112936363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily