Provider Demographics
NPI:1154840460
Name:KELLEY, NICOLE GAIL (MS LOTR)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:GAIL
Last Name:KELLEY
Suffix:
Gender:F
Credentials:MS LOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 MAYHAW ST
Mailing Address - Street 2:
Mailing Address - City:DERIDDER
Mailing Address - State:LA
Mailing Address - Zip Code:70634-2005
Mailing Address - Country:US
Mailing Address - Phone:717-514-7229
Mailing Address - Fax:
Practice Address - Street 1:112 N 3RD ST
Practice Address - Street 2:
Practice Address - City:LEESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71446-4014
Practice Address - Country:US
Practice Address - Phone:337-239-3334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-18
Last Update Date:2017-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA305553225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist