Provider Demographics
NPI:1578698882
Name:KELLY, DENISE RENEA
Entity Type:Individual
Prefix:MS
First Name:DENISE
Middle Name:RENEA
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 1:11330 UNION AVE NORTH EAST
Mailing Address - Street 2:APT 1
Mailing Address - City:ALLIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:44601
Mailing Address - Country:US
Mailing Address - Phone:330-680-3386
Mailing Address - Fax:
Practice Address - Street 1:11330 UNION AVE NORTH EAST
Practice Address - Street 2:APT 1
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601
Practice Address - Country:US
Practice Address - Phone:330-680-3386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
1234OtherPIN
2175846Medicare UPIN