Provider Demographics
NPI:1497369698
Name:CLARK-MILLS, KEELY (RN)
Entity Type:Individual
Prefix:
First Name:KEELY
Middle Name:
Last Name:CLARK-MILLS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 HILLBERG AVE
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-6364
Mailing Address - Country:US
Mailing Address - Phone:617-820-6848
Mailing Address - Fax:
Practice Address - Street 1:335 HILLBERG AVE
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-6364
Practice Address - Country:US
Practice Address - Phone:617-820-6848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-04
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2258668163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WC0400XNursing Service ProvidersRegistered NurseCase ManagementGroup - Single Specialty