Provider Demographics
NPI:1518357706
Name:LAROSE, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:LAROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9513 ELK RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:TN
Mailing Address - Zip Code:38474-2212
Mailing Address - Country:US
Mailing Address - Phone:860-455-3168
Mailing Address - Fax:
Practice Address - Street 1:1221 NASHVILLE HWY
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:TN
Practice Address - Zip Code:37091-2221
Practice Address - Country:US
Practice Address - Phone:860-455-3168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-27
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator