Provider Demographics
NPI:1487616553
Name:CLAUSEN, KELLIE DALE (FNP)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:DALE
Last Name:CLAUSEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:WY
Mailing Address - Zip Code:82633-2434
Mailing Address - Country:US
Mailing Address - Phone:307-358-2122
Mailing Address - Fax:307-358-7381
Practice Address - Street 1:111 S 5TH ST
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:WY
Practice Address - Zip Code:82633-2434
Practice Address - Country:US
Practice Address - Phone:307-358-2122
Practice Address - Fax:307-358-7381
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY14471-0152363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY121710100Medicaid
WY313807OtherBLUECROSS AND BLUESHIELD
WY121710100Medicaid
WY313807OtherBLUECROSS AND BLUESHIELD