Provider Demographics
NPI:1689267718
Name:KELLY, SHERRY
Entity Type:Individual
Prefix:
First Name:SHERRY
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 1:263 LIVINGSTON ST
Mailing Address - Street 2:
Mailing Address - City:SHADY SPRING
Mailing Address - State:WV
Mailing Address - Zip Code:25918-8573
Mailing Address - Country:US
Mailing Address - Phone:304-894-5566
Mailing Address - Fax:
Practice Address - Street 1:263 LIVINGSTON ST
Practice Address - Street 2:
Practice Address - City:SHADY SPRING
Practice Address - State:WV
Practice Address - Zip Code:25918-8573
Practice Address - Country:US
Practice Address - Phone:304-894-5566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-19
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker