Provider Demographics
NPI:1487276739
Name:EASLEY, KELLY JO
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:JO
Last Name:EASLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3169 S BRAND LEE WAY
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85365-5110
Mailing Address - Country:US
Mailing Address - Phone:740-260-0642
Mailing Address - Fax:
Practice Address - Street 1:2701 E 3RD ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-5433
Practice Address - Country:US
Practice Address - Phone:812-332-1419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-09
Last Update Date:2020-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71010029A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily