Provider Demographics
NPI:1477629442
Name:KELLY, SAMANTHA JOSEPHINE (BA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JOSEPHINE
Last Name:KELLY
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7247 W KENTUCKY DR APT A
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80226-4418
Mailing Address - Country:US
Mailing Address - Phone:720-312-0363
Mailing Address - Fax:
Practice Address - Street 1:1733 VINE ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80206-1119
Practice Address - Country:US
Practice Address - Phone:303-504-1037
Practice Address - Fax:303-377-1105
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator