Provider Demographics
NPI:1679934558
Name:KELLY, ERIKA W (DO)
Entity Type:Individual
Prefix:
First Name:ERIKA
Middle Name:W
Last Name:KELLY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1080
Mailing Address - Street 2:
Mailing Address - City:BURKESVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42717-1080
Mailing Address - Country:US
Mailing Address - Phone:270-858-6655
Mailing Address - Fax:270-858-4607
Practice Address - Street 1:404 STEVE DRIVE
Practice Address - Street 2:
Practice Address - City:RUSSELL SPRINGS
Practice Address - State:KY
Practice Address - Zip Code:42642-4622
Practice Address - Country:US
Practice Address - Phone:270-866-3161
Practice Address - Fax:270-866-3163
Is Sole Proprietor?:No
Enumeration Date:2016-03-18
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY04297207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
14562084OtherCAQH
KY7100584270Medicaid