Provider Demographics
NPI:1609271436
Name:KELLY, RESHONDA
Entity Type:Individual
Prefix:
First Name:RESHONDA
Middle Name:
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 1:1048 BLAIRFIELD DR
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-3900
Mailing Address - Country:US
Mailing Address - Phone:615-979-3083
Mailing Address - Fax:
Practice Address - Street 1:1048 BLAIRFIELD DR
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:TN
Practice Address - Zip Code:37013-3900
Practice Address - Country:US
Practice Address - Phone:615-979-3083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-22
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN183448172A00000X, 343800000X, 343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343800000XTransportation ServicesSecured Medical Transport (VAN)
No172A00000XOther Service ProvidersDriver
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)