Provider Demographics
NPI:1861052862
Name:MEYER, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MEYER
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 1:3698 STATE HIGHWAY 241
Mailing Address - Street 2:
Mailing Address - City:AFTON
Mailing Address - State:WY
Mailing Address - Zip Code:83110-9758
Mailing Address - Country:US
Mailing Address - Phone:218-298-1548
Mailing Address - Fax:
Practice Address - Street 1:3698 STATE HIGHWAY 241
Practice Address - Street 2:
Practice Address - City:AFTON
Practice Address - State:WY
Practice Address - Zip Code:83110-9758
Practice Address - Country:US
Practice Address - Phone:218-298-1548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-20
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide