Provider Demographics
NPI:1417155656
Name:FAWCETT, KELLY N (NP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:N
Last Name:FAWCETT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9604 COLDWATER RD STE 207
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-2096
Mailing Address - Country:US
Mailing Address - Phone:260-438-8819
Mailing Address - Fax:260-383-8368
Practice Address - Street 1:9604 COLDWATER RD STE 207
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-2096
Practice Address - Country:US
Practice Address - Phone:260-438-8819
Practice Address - Fax:260-383-8368
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2025-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002401A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200867390Medicaid
IN259990EEMedicare PIN