Provider Demographics
NPI:1447505862
Name:WOODFORD, KELLY RHEA (FNP-BC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:RHEA
Last Name:WOODFORD
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:JANE
Other - Last Name:RHEA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:PO BOX 3810
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803-3810
Mailing Address - Country:US
Mailing Address - Phone:417-347-4662
Mailing Address - Fax:417-347-9453
Practice Address - Street 1:3415 MCINTOSH CIR
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3651
Practice Address - Country:US
Practice Address - Phone:417-347-4000
Practice Address - Fax:417-347-4064
Is Sole Proprietor?:No
Enumeration Date:2012-07-23
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018043161363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner