Provider Demographics
NPI:1871957225
Name:PROUD, KELLY CHOATE (APRN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:CHOATE
Last Name:PROUD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:JEAN
Other - Last Name:CHOATE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6425 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-2101
Mailing Address - Country:US
Mailing Address - Phone:859-282-0431
Mailing Address - Fax:859-282-1482
Practice Address - Street 1:6425 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-2101
Practice Address - Country:US
Practice Address - Phone:859-282-0431
Practice Address - Fax:859-282-1482
Is Sole Proprietor?:No
Enumeration Date:2016-04-12
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3010228363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100395480Medicaid
KYK200610Medicare PIN