Provider Demographics
NPI:1003310921
Name:KELTY, STEPHANIE RAE (APRN)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:RAE
Last Name:KELTY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:1301 RING RD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-8968
Practice Address - Country:US
Practice Address - Phone:270-765-2107
Practice Address - Fax:270-769-9642
Is Sole Proprietor?:No
Enumeration Date:2018-03-23
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY3012197363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics