Provider Demographics
NPI:1730544933
Name:KELLEY, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KELLEY
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 1:800 SAGUARO TRL
Mailing Address - Street 2:SAN JUAN COLLEGE OTA PROGRAM
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-9632
Mailing Address - Country:US
Mailing Address - Phone:505-598-6000
Mailing Address - Fax:
Practice Address - Street 1:800 SAGUARO TRL
Practice Address - Street 2:SAN JUAN COLLEGE OTA PROGRAM
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-9632
Practice Address - Country:US
Practice Address - Phone:505-598-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-15
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2526225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist