Provider Demographics
NPI:1497142996
Name:KELLEY, KEVIN (RN, CDOE)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:KELLEY
Suffix:
Gender:M
Credentials:RN, CDOE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 COMMERCE ST
Mailing Address - Street 2:CENTRAL ADMINISTRATION
Mailing Address - City:LINCOLN
Mailing Address - State:RI
Mailing Address - Zip Code:02865-1186
Mailing Address - Country:US
Mailing Address - Phone:401-793-8392
Mailing Address - Fax:401-793-8391
Practice Address - Street 1:400 BALD HILL RD
Practice Address - Street 2:SUITE 520
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-1617
Practice Address - Country:US
Practice Address - Phone:401-793-8520
Practice Address - Fax:401-793-8527
Is Sole Proprietor?:No
Enumeration Date:2015-04-22
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRN47992163WC0400X, 163WD0400X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163W00000XNursing Service ProvidersRegistered Nurse