Provider Demographics
NPI:1013381482
Name:KELLEY, RYAN JEROME
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:JEROME
Last Name:KELLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6468 DEERWOOD LN
Mailing Address - Street 2:
Mailing Address - City:LINO LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:55014-5428
Mailing Address - Country:US
Mailing Address - Phone:612-669-5506
Mailing Address - Fax:
Practice Address - Street 1:1400 HIGHLAND CTR
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6537
Practice Address - Country:US
Practice Address - Phone:612-669-5506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-21
Last Update Date:2015-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program