Provider Demographics
NPI:1437637428
Name:KELLEY, VIVIA PAULETTE (LVN)
Entity Type:Individual
Prefix:
First Name:VIVIA
Middle Name:PAULETTE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 PRINCE OF WALES ST
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-2717
Mailing Address - Country:US
Mailing Address - Phone:936-524-7390
Mailing Address - Fax:
Practice Address - Street 1:13662 BIGHORN TRL
Practice Address - Street 2:
Practice Address - City:WILLIS
Practice Address - State:TX
Practice Address - Zip Code:77378-4058
Practice Address - Country:US
Practice Address - Phone:936-524-7390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-01
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX172973164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse