Provider Demographics
NPI:1528084282
Name:KELL, STACI W (APRN)
Entity type:Individual
Prefix:MS
First Name:STACI
Middle Name:W
Last Name:KELL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:STACI
Other - Middle Name:W
Other - Last Name:FOOSHEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:83 WELLNESS WAY STE 101&201
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:KY
Mailing Address - Zip Code:42025-7156
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:83 WELLNESS WAY STE 101&201
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:KY
Practice Address - Zip Code:42025-7156
Practice Address - Country:US
Practice Address - Phone:270-527-0045
Practice Address - Fax:270-527-9615
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3004803363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78017720Medicaid
KYK127020Medicare PIN