Provider Demographics
NPI:1902568892
Name:KELLEY, MIKAYLA (PA)
Entity Type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MIKAYLA
Other - Middle Name:
Other - Last Name:ALDRICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4508 38TH ST STE 133
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:NE
Mailing Address - Zip Code:68601-1668
Mailing Address - Country:US
Mailing Address - Phone:402-562-4700
Mailing Address - Fax:402-562-4701
Practice Address - Street 1:4508 38TH ST STE 133
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:NE
Practice Address - Zip Code:68601-1668
Practice Address - Country:US
Practice Address - Phone:402-562-4700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-08
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2663207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty