Provider Demographics
NPI:1225715394
Name:DANIEL, KELLY (MS)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:DANIEL
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 MERRYWOOD DR APT 2
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-8715
Mailing Address - Country:US
Mailing Address - Phone:770-714-3863
Mailing Address - Fax:
Practice Address - Street 1:1043 JACK VEST DRIVE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37614
Practice Address - Country:US
Practice Address - Phone:423-439-4044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-30
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program