Provider Demographics
NPI:1568715183
Name:NANCY KELLEY, MD, LLC
Entity Type:Organization
Organization Name:NANCY KELLEY, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:DIETZ
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:303-442-2913
Mailing Address - Street 1:4745 ARAPAHOE AVE
Mailing Address - Street 2:SUITE 310
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-1080
Mailing Address - Country:US
Mailing Address - Phone:303-442-2913
Mailing Address - Fax:303-444-6198
Practice Address - Street 1:4745 ARAPAHOE AVE
Practice Address - Street 2:SUITE 310
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-1080
Practice Address - Country:US
Practice Address - Phone:303-442-2913
Practice Address - Fax:303-444-6198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-19
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO48271261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care