Provider Demographics
NPI:1659664597
Name:EGAN, KELLY
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:
Last Name:EGAN
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 1:1124 E BRECKINRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40204-1856
Mailing Address - Country:US
Mailing Address - Phone:502-807-5631
Mailing Address - Fax:
Practice Address - Street 1:1124 E BRECKINRIDGE ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40204-1856
Practice Address - Country:US
Practice Address - Phone:502-807-5631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-25
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist