Provider Demographics
NPI:1487115614
Name:STANKO, KELSEY LOFGREN (MSN, RN, CPNP-PC)
Entity type:Individual
Prefix:MRS
First Name:KELSEY
Middle Name:LOFGREN
Last Name:STANKO
Suffix:
Gender:F
Credentials:MSN, RN, CPNP-PC
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:LEIGH
Other - Last Name:LOFGREN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN, RN, CPNP-PC
Mailing Address - Street 1:4600 WATERS AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-6274
Mailing Address - Country:US
Mailing Address - Phone:912-355-2462
Mailing Address - Fax:
Practice Address - Street 1:4600 WATERS AVE STE 100
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-6274
Practice Address - Country:US
Practice Address - Phone:912-355-2462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-29
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC25413208000000X
GA250178363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty