Provider Demographics
NPI:1346855517
Name:KELLEY, RYAN MICHAEL (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:MICHAEL
Last Name:KELLEY
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 RUE COLETTE
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-5628
Mailing Address - Country:US
Mailing Address - Phone:985-625-0023
Mailing Address - Fax:985-625-0022
Practice Address - Street 1:126 RUE COLETTE
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-5628
Practice Address - Country:US
Practice Address - Phone:985-625-0023
Practice Address - Fax:985-625-0022
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA214914363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health