Provider Demographics
NPI:1972334282
Name:KELLAMS, CASSANDRA L
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:L
Last Name:KELLAMS
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 1:10782 W OLD VINCENNES RD
Mailing Address - Street 2:
Mailing Address - City:WEST BADEN SPRINGS
Mailing Address - State:IN
Mailing Address - Zip Code:47469-9669
Mailing Address - Country:US
Mailing Address - Phone:812-508-1143
Mailing Address - Fax:
Practice Address - Street 1:10782 W OLD VINCENNES RD
Practice Address - Street 2:
Practice Address - City:WEST BADEN SPRINGS
Practice Address - State:IN
Practice Address - Zip Code:47469-9669
Practice Address - Country:US
Practice Address - Phone:812-508-1143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28197391A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily