Provider Demographics
NPI:1083181358
Name:KELLY, MEAGHAN A (LAC)
Entity Type:Individual
Prefix:
First Name:MEAGHAN
Middle Name:A
Last Name:KELLY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:83 INDIA ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-4210
Mailing Address - Country:US
Mailing Address - Phone:207-347-7132
Mailing Address - Fax:207-347-3527
Practice Address - Street 1:83 INDIA ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-4210
Practice Address - Country:US
Practice Address - Phone:207-347-7132
Practice Address - Fax:207-347-3527
Is Sole Proprietor?:No
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAC613171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist