Provider Demographics
NPI:1033735675
Name:THAYER, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:THAYER
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 1:1 SULLIVAN TER
Mailing Address - Street 2:
Mailing Address - City:BARRINGTON
Mailing Address - State:RI
Mailing Address - Zip Code:02806-3501
Mailing Address - Country:US
Mailing Address - Phone:401-245-9608
Mailing Address - Fax:
Practice Address - Street 1:125 BAY VIEW AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:RI
Practice Address - Zip Code:02915-4955
Practice Address - Country:US
Practice Address - Phone:401-529-8884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-19
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRN60197163WH0200X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WH0200XNursing Service ProvidersRegistered NurseHome Health