Provider Demographics
NPI:1154655512
Name:KELLEY, AMY KRISTINE (RPH)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:KRISTINE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2320 FAIRWAY TER
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-2724
Mailing Address - Country:US
Mailing Address - Phone:575-763-4161
Mailing Address - Fax:
Practice Address - Street 1:3728 N PRINCE ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-9744
Practice Address - Country:US
Practice Address - Phone:575-769-2389
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-01
Last Update Date:2014-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5544183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM5544OtherNEW MEXICO BOARD OF PHARMACY LICENSE NUMBER