Provider Demographics
NPI:1285845453
Name:KELLEY, DIANE E (LMT)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:E
Last Name:KELLEY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1054 NOCTURNE RD E
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-2016
Mailing Address - Country:US
Mailing Address - Phone:614-561-9183
Mailing Address - Fax:614-367-9281
Practice Address - Street 1:6422 E MAIN ST
Practice Address - Street 2:SUITE 102
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-2358
Practice Address - Country:US
Practice Address - Phone:614-561-9183
Practice Address - Fax:614-367-9281
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-26
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH11532225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist