Provider Demographics
NPI:1386181485
Name:KELLEY, VANESSA (MS, ATC)
Entity Type:Individual
Prefix:MRS
First Name:VANESSA
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 339
Mailing Address - Street 2:
Mailing Address - City:WAIMEA
Mailing Address - State:HI
Mailing Address - Zip Code:96796-0339
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9707 TSUCHIYA ROAD
Practice Address - Street 2:
Practice Address - City:WAIMEA
Practice Address - State:HI
Practice Address - Zip Code:96796
Practice Address - Country:US
Practice Address - Phone:808-338-6810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-26
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI232255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer