Provider Demographics
NPI:1932656311
Name:EDWARDS, KELLEY R (FNP-C)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:R
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:R
Other - Last Name:CHAMBERS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:244 WESTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-5687
Practice Address - Country:US
Practice Address - Phone:812-669-0141
Practice Address - Fax:812-799-7062
Is Sole Proprietor?:No
Enumeration Date:2016-09-02
Last Update Date:2025-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71006506A363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ININ1125026OtherMEDICARE PTAN
IN201386320Medicaid
ININ1127025OtherMEDICARE PTAN