Provider Demographics
NPI:1730566647
Name:KELLY, DONNA L (NP-C)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:L
Last Name:KELLY
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 98978
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89193-8978
Mailing Address - Country:US
Mailing Address - Phone:702-216-3346
Mailing Address - Fax:702-671-6883
Practice Address - Street 1:1501 E CALVADA BLVD
Practice Address - Street 2:
Practice Address - City:PAHRUMP
Practice Address - State:NV
Practice Address - Zip Code:89048-5807
Practice Address - Country:US
Practice Address - Phone:775-727-5500
Practice Address - Fax:775-727-5696
Is Sole Proprietor?:No
Enumeration Date:2015-04-29
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NVAPRN001938363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1730566647Medicaid
NV1730566647Medicaid