Provider Demographics
NPI:1558348763
Name:KELLEY, LAURA (DO)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:295 FOREST AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-2018
Mailing Address - Country:US
Mailing Address - Phone:207-772-5437
Mailing Address - Fax:207-879-1537
Practice Address - Street 1:295 FOREST AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2018
Practice Address - Country:US
Practice Address - Phone:207-772-5437
Practice Address - Fax:207-879-1537
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1865208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEH98890Medicare UPIN