Provider Demographics
NPI:1083890503
Name:KELLY, EDWARD LAWRENCE JR (LPN)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:LAWRENCE
Last Name:KELLY
Suffix:JR
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:RED OAK
Mailing Address - State:IA
Mailing Address - Zip Code:51566-2439
Mailing Address - Country:US
Mailing Address - Phone:712-623-6862
Mailing Address - Fax:
Practice Address - Street 1:711 S VINE ST
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:IA
Practice Address - Zip Code:51534-1927
Practice Address - Country:US
Practice Address - Phone:712-525-1344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-15
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAP12593164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse