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
StateLicense IDTaxonomies
KYR3750207Q00000X
390200000X
KY51438207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100432940Medicaid