Provider Demographics
NPI:1598390742
Name:KELLY, SOPHIA JEAN
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:JEAN
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 1:700 PUJO ST STE A
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-4378
Mailing Address - Country:US
Mailing Address - Phone:337-436-6662
Mailing Address - Fax:
Practice Address - Street 1:700 PUJO ST STE A
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-4378
Practice Address - Country:US
Practice Address - Phone:337-436-6662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-09
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant