Provider Demographics
NPI:1578062519
Name:KELLY, MICHELLE MARIE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
Last Name:KELLY
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 1:61 SUNRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01118-2440
Mailing Address - Country:US
Mailing Address - Phone:413-885-4744
Mailing Address - Fax:
Practice Address - Street 1:108 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SUNDERLAND
Practice Address - State:MA
Practice Address - Zip Code:01375-9502
Practice Address - Country:US
Practice Address - Phone:413-665-8717
Practice Address - Fax:413-665-9383
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-05
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker