Provider Demographics
NPI:1326695248
Name:NOEL, KELLY SUZANNE (LMT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:SUZANNE
Last Name:NOEL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 BENNINGFIELD CEMETERY RD
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-6548
Mailing Address - Country:US
Mailing Address - Phone:270-403-0528
Mailing Address - Fax:
Practice Address - Street 1:108 LEBANON AVE
Practice Address - Street 2:
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-1839
Practice Address - Country:US
Practice Address - Phone:270-403-0528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-26
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY163314225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist