Provider Demographics
NPI:1538718135
Name:KELLY, MAE
Entity type:Individual
Prefix:MISS
First Name:MAE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2207 N MAGNOLIA DR
Mailing Address - Street 2:
Mailing Address - City:BAKER
Mailing Address - State:LA
Mailing Address - Zip Code:70714-3223
Mailing Address - Country:US
Mailing Address - Phone:225-936-1097
Mailing Address - Fax:
Practice Address - Street 1:2929 MILLERVILLE RD STE E
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-2965
Practice Address - Country:US
Practice Address - Phone:225-349-8984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-05
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator