Provider Demographics
NPI:1720246010
Name:BEAN, KELLY J (NP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:BEAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 869
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46061-0869
Mailing Address - Country:US
Mailing Address - Phone:317-770-6900
Mailing Address - Fax:317-770-6911
Practice Address - Street 1:14540 PRAIRIE LAKES BLVD N
Practice Address - Street 2:SUITE 200
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-4366
Practice Address - Country:US
Practice Address - Phone:317-578-4193
Practice Address - Fax:317-842-8412
Is Sole Proprietor?:No
Enumeration Date:2008-05-23
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002643A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000568239OtherANTHEM
IN200900770Medicaid