Provider Demographics
NPI:1174863898
Name:KELLEY, LATRECA MARIE (CMA/CNA)
Entity Type:Individual
Prefix:
First Name:LATRECA
Middle Name:MARIE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:CMA/CNA
Other - Prefix:
Other - First Name:LATRECA
Other - Middle Name:MARIE
Other - Last Name:MARKS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 20803
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-6803
Mailing Address - Country:US
Mailing Address - Phone:316-347-6633
Mailing Address - Fax:
Practice Address - Street 1:4438 E FALCON ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67220-1776
Practice Address - Country:US
Practice Address - Phone:316-347-6633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-15
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS374U00000X
KS05352376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No374U00000XNursing Service Related ProvidersHome Health Aide