1427339597 NPI number — MS. REBECCA KATHLEEN KELLN PA-C

Table of content: MS. REBECCA KATHLEEN KELLN PA-C (NPI 1427339597)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427339597 NPI number — MS. REBECCA KATHLEEN KELLN PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLN
Provider First Name:
REBECCA
Provider Middle Name:
KATHLEEN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1427339597
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/14/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3245 HEALTH DRIVE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
GRANGER
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46530-3245
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-647-1840
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 NAVARRE PL STE 5550
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH BEND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46601-1169
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-647-2550
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/02/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  10002837A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , with the licence number: 5601006095 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 300032358 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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