Provider Demographics
NPI:1427128321
Name:WILLIAMS, KELLY A (MSN - FNP-C)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:A
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:MSN - FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 S. WEST ST
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307
Mailing Address - Country:US
Mailing Address - Phone:219-552-8188
Mailing Address - Fax:219-310-8090
Practice Address - Street 1:166 S. WEST ST.
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307
Practice Address - Country:US
Practice Address - Phone:219-552-8188
Practice Address - Fax:484-351-3800
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041356170363LF0000X
IN71001088B363LF0000X
IN28096681A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP18818Medicare UPIN