Provider Demographics
NPI:1831600311
Name:ROE, KELLI ROSE (NP)
Entity type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:ROSE
Last Name:ROE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4813 NEW HAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46803-3018
Mailing Address - Country:US
Mailing Address - Phone:260-449-7504
Mailing Address - Fax:
Practice Address - Street 1:4813 NEW HAVEN AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46803-3018
Practice Address - Country:US
Practice Address - Phone:260-449-7504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-24
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28181384A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily