Provider Demographics
NPI:1639878598
Name:KELLEY, SONYA A (LPN)
Entity Type:Individual
Prefix:
First Name:SONYA
Middle Name:A
Last Name:KELLEY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 S WINTER ST
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-3876
Mailing Address - Country:US
Mailing Address - Phone:517-263-8905
Mailing Address - Fax:
Practice Address - Street 1:1040 S WINTER ST
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-3876
Practice Address - Country:US
Practice Address - Phone:517-263-8905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-01
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703126341164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI383400932Medicaid