Provider Demographics
NPI:1427671080
Name:BAXTER, KELLY LEA (PHARMD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LEA
Last Name:BAXTER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:LEA
Other - Last Name:COLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4449 WOOLWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68105-1756
Mailing Address - Country:US
Mailing Address - Phone:651-341-9829
Mailing Address - Fax:
Practice Address - Street 1:4101 WOOLWORTH AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68105-1850
Practice Address - Country:US
Practice Address - Phone:402-995-3442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-18
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE16528183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist