Basic Information
| Provider Information | |||||||||
| NPI: | 1558605337 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | W. | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | FNP-C APRN, MSN, MSM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 TWINING ST BLDG 760 | ||||||||
| Address2: | |||||||||
| City: | MAXWELL AFB | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361126027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3349535143 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 300 TWINING ST | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361126027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3349535143 | ||||||||
| FaxNumber: | 3349538607 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2012 | ||||||||
| LastUpdateDate: | 06/13/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | R861157 | MS | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363LF0000X | 44039 | WY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.