Provider Demographics
NPI:1912393570
Name:HORN, KELLY R
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:R
Last Name:HORN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 E 9TH ST
Mailing Address - Street 2:
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-2209
Mailing Address - Country:US
Mailing Address - Phone:319-651-5173
Mailing Address - Fax:319-467-2510
Practice Address - Street 1:105 E 9TH ST
Practice Address - Street 2:
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-2209
Practice Address - Country:US
Practice Address - Phone:319-651-5173
Practice Address - Fax:319-467-2510
Is Sole Proprietor?:No
Enumeration Date:2015-04-10
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN09000257A176B00000X
IN71005416A363L00000X
IAB180964367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner