Provider Demographics
NPI:1508503012
Name:KELLEY, KAITLIN (PMHNP)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 WOODLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02917-4116
Mailing Address - Country:US
Mailing Address - Phone:401-855-5923
Mailing Address - Fax:
Practice Address - Street 1:382 THAYER ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-1558
Practice Address - Country:US
Practice Address - Phone:401-855-5923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-16
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIAPRN03091363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health