Provider Demographics
NPI:1396978441
Name:KELLY, KAREN (EDD, RN, NEA-BC)
Entity type:Individual
Prefix:DR
First Name:KAREN
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:EDD, RN, NEA-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CAMPUS BOX 1066
Mailing Address - Street 2:SOUTHERN ILLINOIS UNIVERSITY EDWARDSVILLE
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62026-1066
Mailing Address - Country:US
Mailing Address - Phone:618-650-3908
Mailing Address - Fax:618-650-2522
Practice Address - Street 1:CAMPUS BOX 1066
Practice Address - Street 2:SOUTHERN ILLINOIS UNIVERSITY EDWARDSVILLE
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62026-1066
Practice Address - Country:US
Practice Address - Phone:618-650-3908
Practice Address - Fax:618-650-2522
Is Sole Proprietor?:No
Enumeration Date:2009-08-24
Last Update Date:2009-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-144845163WA2000X
MO064395163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator