Provider Demographics
NPI:1114021417
Name:KELLEY, REBECCA ANN (RN)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANN
Last Name:KELLEY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1715 BIG BEND RD
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-2916
Mailing Address - Country:US
Mailing Address - Phone:573-778-0995
Mailing Address - Fax:
Practice Address - Street 1:220 E BROAD ST
Practice Address - Street 2:
Practice Address - City:NAYLOR
Practice Address - State:MO
Practice Address - Zip Code:63953
Practice Address - Country:US
Practice Address - Phone:573-399-2311
Practice Address - Fax:573-399-2646
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO151395163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse