Provider Demographics
NPI:1538656145
Name:TODD, KELLY COTALEEN (PNP)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:COTALEEN
Last Name:TODD
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2646 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-2024
Mailing Address - Country:US
Mailing Address - Phone:815-310-6222
Mailing Address - Fax:
Practice Address - Street 1:25340 1300 EAST ST
Practice Address - Street 2:
Practice Address - City:WALNUT
Practice Address - State:IL
Practice Address - Zip Code:61376-9274
Practice Address - Country:US
Practice Address - Phone:815-310-6222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-18
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMCS006520B363LP0200X
MO2018004205363LP0200X
IL277001500363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420071827Medicaid