Provider Demographics
NPI:1447568795
Name:KELLEY, AMY KATHLEEN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:KATHLEEN
Last Name:KELLEY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:AMY
Other - Middle Name:KATHLEEN
Other - Last Name:PINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:9012 MEISENHEIMER AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89143-4425
Mailing Address - Country:US
Mailing Address - Phone:702-494-7463
Mailing Address - Fax:
Practice Address - Street 1:4700 LAS VEGAS BLVD N
Practice Address - Street 2:
Practice Address - City:NELLIS AFB
Practice Address - State:NV
Practice Address - Zip Code:89191-6600
Practice Address - Country:US
Practice Address - Phone:702-653-3212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-21
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS44510183500000X
GARPH024665183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARPH024665OtherPHARMACIST LICENSE
FLPS44510OtherPHARMACIST LICENSE