Individual ProviderKelly DavisNurse PractitionerPhysician Assistants & Advanced Practice Nursing ProvidersPractice Address6326 Constitution Dr, Fort Wayne, IN 46804-1518(260) 969-6200(260) 466-8908PECOS EnrollmentBased on the most recent information from CMS, provider Kelly Davis is legally eligible to order and refer claims for Part B, HHA, DME and PMD services.Part BMedicare Part BEnrolledHHAHome Health AgencyEnrolledDMEDurable Medical EquipmentEnrolledPMDPower Mobility DeviceEnrolledCMS last updated its PECOS records yesterday at 12:57 PM.Profile DetailsProvider ID1699388496Provider TypeIndividualFull NameDavis, KellyCredentialFNPGenderFemaleSole ProprietorYesEnumeration Date8/31/2020Last Updated8/31/2020Contact InformationPractice LocationPractice Address6326 Constitution Dr, Fort Wayne, IN 46804-1518Phone(260) 969-6200FaxUnlisted FaxMailing LocationMailing Address4107 Rocky Knoll Ct, Fort Wayne, IN 46809-9534Phone(260) 466-8908FaxUnlisted FaxProvider TaxonomiesCodeDescriptionLicenseCode363LF0000XPrimaryDescriptionNurse PractitionerPhysician Assistants & Advanced Practice Nursing ProvidersLicense71010315AIndiana