Provider Demographics
NPI:1962724344
Name:CARRICO, KELLY JO (NNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JO
Last Name:CARRICO
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4199 GATEWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630-8940
Mailing Address - Country:US
Mailing Address - Phone:812-842-4575
Mailing Address - Fax:812-842-4549
Practice Address - Street 1:4199 GATEWAY BLVD
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-8940
Practice Address - Country:US
Practice Address - Phone:812-842-4575
Practice Address - Fax:812-842-4549
Is Sole Proprietor?:No
Enumeration Date:2010-02-25
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010006352363LN0000X
IN71003817A363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal