Provider Demographics
NPI:1447924758
Name:KELLEY-WISE, NATASHA NICOLE (APRN)
Entity type:Individual
Prefix:
First Name:NATASHA
Middle Name:NICOLE
Last Name:KELLEY-WISE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:816 22ND AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68845-2206
Mailing Address - Country:US
Mailing Address - Phone:308-865-2263
Mailing Address - Fax:
Practice Address - Street 1:816 22ND AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68845-2206
Practice Address - Country:US
Practice Address - Phone:308-865-2263
Practice Address - Fax:308-865-2541
Is Sole Proprietor?:No
Enumeration Date:2021-08-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE113722363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner