Provider Demographics
NPI:1518545284
Name:KELLY, LATONYA R (OWNER)
Entity type:Individual
Prefix:
First Name:LATONYA
Middle Name:R
Last Name:KELLY
Suffix:
Gender:F
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6517 ROYAL OAKLAND DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46236-4805
Mailing Address - Country:US
Mailing Address - Phone:317-657-0510
Mailing Address - Fax:
Practice Address - Street 1:6517 ROYAL OAKLAND DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46236-4805
Practice Address - Country:US
Practice Address - Phone:317-657-0510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-01
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN300047703251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300047703Medicaid