Provider Demographics
NPI:1508471707
Name:KELLY, OPIE LEE
Entity Type:Individual
Prefix:
First Name:OPIE
Middle Name:LEE
Last Name:KELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2638 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:NITRO
Mailing Address - State:WV
Mailing Address - Zip Code:25143-1724
Mailing Address - Country:US
Mailing Address - Phone:304-941-8971
Mailing Address - Fax:
Practice Address - Street 1:2638 3RD AVE
Practice Address - Street 2:
Practice Address - City:NITRO
Practice Address - State:WV
Practice Address - Zip Code:25143-1724
Practice Address - Country:US
Practice Address - Phone:304-941-8971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-14
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant