Provider Demographics
NPI:1669685830
Name:KELLEY, SANDRA (PA)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:
Other - Last Name:ROGNALSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:823 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HOPE VALLEY
Mailing Address - State:RI
Mailing Address - Zip Code:02832-1920
Mailing Address - Country:US
Mailing Address - Phone:401-539-2461
Mailing Address - Fax:401-753-6348
Practice Address - Street 1:823 MAIN ST
Practice Address - Street 2:
Practice Address - City:HOPE VALLEY
Practice Address - State:RI
Practice Address - Zip Code:02832-1920
Practice Address - Country:US
Practice Address - Phone:401-539-2461
Practice Address - Fax:401-753-6348
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA00811363AM0700X
CT001044363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical