Provider Demographics
NPI:1407369002
Name:KELLEY, VICTORIA MARIE
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:MARIE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7788 LOCKE HAVEN DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89123-0734
Mailing Address - Country:US
Mailing Address - Phone:702-462-1790
Mailing Address - Fax:
Practice Address - Street 1:6605 ALTA DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89107-3376
Practice Address - Country:US
Practice Address - Phone:702-462-1790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-06
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor