Provider Demographics
NPI: | 1467848952 |
---|---|
Name: | DEATLEY, KELLY RENEE (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | KELLY |
Middle Name: | RENEE |
Last Name: | DEATLEY |
Suffix: | |
Gender: | F |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | KELLY |
Other - Middle Name: | RENEE |
Other - Last Name: | MURPHY |
Other - Suffix: | |
Other - Last Name Type: | Former Name |
Other - Credentials: | MD |
Mailing Address - Street 1: | 325 W WALNUT ST STE 600 |
Mailing Address - Street 2: | |
Mailing Address - City: | LEBANON |
Mailing Address - State: | KY |
Mailing Address - Zip Code: | 40033-1378 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 270-699-9500 |
Mailing Address - Fax: | 270-699-9550 |
Practice Address - Street 1: | 325 W WALNUT ST STE 600 |
Practice Address - Street 2: | |
Practice Address - City: | LEBANON |
Practice Address - State: | KY |
Practice Address - Zip Code: | 40033 |
Practice Address - Country: | US |
Practice Address - Phone: | 270-699-9500 |
Practice Address - Fax: | 270-699-9550 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2015-04-10 |
Last Update Date: | 2018-06-26 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
KY | R3750 | 207Q00000X |
390200000X | ||
KY | 51438 | 207Q00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | |
No | 390200000X | Student, Health Care | Student in an Organized Health Care Education/Training Program |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
KY | 7100432940 | Medicaid |