Provider Demographics
NPI:1174872600
Name:KELLY, JENNY LYNN (APNP)
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:LYNN
Last Name:KELLY
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
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Mailing Address - Street 1:164 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-2728
Mailing Address - Country:US
Mailing Address - Phone:920-965-4055
Mailing Address - Fax:920-405-5388
Practice Address - Street 1:2845 GREENBRIER RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6519
Practice Address - Country:US
Practice Address - Phone:920-288-4060
Practice Address - Fax:920-288-4067
Is Sole Proprietor?:No
Enumeration Date:2012-08-30
Last Update Date:2013-11-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI4936-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1174872600Medicaid