Provider Demographics
NPI:1013387000
Name:WAHL, KELLIE ANN (NP-C)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:ANN
Last Name:WAHL
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2329 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:BOYNE FALLS
Mailing Address - State:MI
Mailing Address - Zip Code:49713-9268
Mailing Address - Country:US
Mailing Address - Phone:231-535-2822
Mailing Address - Fax:833-992-2439
Practice Address - Street 1:1108 VALENTINE CIR
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37405-2866
Practice Address - Country:US
Practice Address - Phone:231-920-5625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-02
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704291998363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner