Provider Demographics
NPI:1467069211
Name:KELLY, KENDRA
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:
Last Name:KELLY
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 1:124 AMBERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HARVEST
Mailing Address - State:AL
Mailing Address - Zip Code:35749-9227
Mailing Address - Country:US
Mailing Address - Phone:256-483-0433
Mailing Address - Fax:
Practice Address - Street 1:810 FRANKLIN ST SE STE A
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-4310
Practice Address - Country:US
Practice Address - Phone:256-533-7676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-25
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALF08190461363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily