Provider Demographics
NPI:1205180718
Name:KELLY, ANGELA M (OTR/L)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:KELLY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 315
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39158
Mailing Address - Country:US
Mailing Address - Phone:601-206-9195
Mailing Address - Fax:601-957-8391
Practice Address - Street 1:3261 HWY 49 SOUTH
Practice Address - Street 2:VA STATE HOME/COLLINS
Practice Address - City:COLLINS
Practice Address - State:MS
Practice Address - Zip Code:39428
Practice Address - Country:US
Practice Address - Phone:601-206-9195
Practice Address - Fax:601-957-8391
Is Sole Proprietor?:No
Enumeration Date:2012-11-06
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT0277225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014160Medicaid
MS25-6542Medicare UPIN