Basic Information
| Provider Information | |||||||||
| NPI: | 1265499669 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SCHAAR-EVISTON | ||||||||
| FirstName: | KELLI | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 CHAMBER CENTER DRIVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | FORT MITCHELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410171673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593445555 | ||||||||
| FaxNumber: | 8596554395 | ||||||||
| Practice Location | |||||||||
| Address1: | 5522 TAYLOR MILL RD | ||||||||
| Address2: | |||||||||
| City: | TAYLOR MILL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410154604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8594912855 | ||||||||
| FaxNumber: | 8596554395 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2006 | ||||||||
| LastUpdateDate: | 09/26/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 1092435 | KY | N | Nursing Service Providers | Registered Nurse | 363L00000X | 3003042 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 78003936 | 05 | KY | MEDICAID | 2498980 | 05 | OH | MEDICAID |