Provider Demographics
NPI:1265001655
Name:KELLEY, MAMIE
Entity Type:Individual
Prefix:
First Name:MAMIE
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11710 BRIAR FOREST DR APT 1806
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77077-5043
Mailing Address - Country:US
Mailing Address - Phone:616-334-3602
Mailing Address - Fax:
Practice Address - Street 1:11710 BRIAR FOREST DR APT 1806
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77077-5043
Practice Address - Country:US
Practice Address - Phone:616-334-3602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-21
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist