Provider Demographics
NPI:1134660038
Name:MARCHEL KELLEY
Entity type:Organization
Organization Name:MARCHEL KELLEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FSP
Authorized Official - Prefix:MISS
Authorized Official - First Name:ANN
Authorized Official - Middle Name:M
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-620-1821
Mailing Address - Street 1:5 N WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:WY
Mailing Address - Zip Code:82834-2014
Mailing Address - Country:US
Mailing Address - Phone:307-620-1821
Mailing Address - Fax:
Practice Address - Street 1:5 N WYOMING AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:WY
Practice Address - Zip Code:82834-2014
Practice Address - Country:US
Practice Address - Phone:307-620-1821
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-13
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization