Provider Demographics
NPI:1407092158
Name:KELLEY, RUDELLA KAY (RN)
Entity Type:Individual
Prefix:MS
First Name:RUDELLA
Middle Name:KAY
Last Name:KELLEY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 JOEL DR
Mailing Address - Street 2:
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223-5318
Mailing Address - Country:US
Mailing Address - Phone:270-798-8503
Mailing Address - Fax:270-956-0227
Practice Address - Street 1:650 JOEL DR
Practice Address - Street 2:
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5318
Practice Address - Country:US
Practice Address - Phone:270-798-8503
Practice Address - Fax:270-956-0227
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-31
Last Update Date:2008-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000151286163WA2000X
KY2004337787163WW0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator
No163WW0000XNursing Service ProvidersRegistered NurseWound Care