Provider Demographics
NPI:1053370072
Name:WILLBUR, KELLY L (ARNP)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:L
Last Name:WILLBUR
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-272-5063
Mailing Address - Fax:502-272-5339
Practice Address - Street 1:3026 POPLAR LEVEL RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1301
Practice Address - Country:US
Practice Address - Phone:502-636-4929
Practice Address - Fax:502-394-3629
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN71002097363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily