Provider Demographics
NPI:1588638969
Name:COLE, KELLY L (DO)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:COLE
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:PO BOX 310
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:KY
Mailing Address - Zip Code:42450-0310
Mailing Address - Country:US
Mailing Address - Phone:270-667-2023
Mailing Address - Fax:270-667-7518
Practice Address - Street 1:121 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:KY
Practice Address - Zip Code:42450-1268
Practice Address - Country:US
Practice Address - Phone:270-667-2023
Practice Address - Fax:270-667-7518
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02437207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY00000043968OtherANTHEM BLUE CROSS & BLUE
027299800OtherBLACK LUNG
KY1103582Medicaid
1386132OtherTHE FUNDS ID
KY64024375Medicaid
KY1103582Medicaid
KY64024375Medicaid