Provider Demographics
NPI:1699813212
Name:KELLEY, SANDRA TRACEY (NP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:TRACEY
Last Name:KELLEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 FOREST LAKE DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40515-6299
Mailing Address - Country:US
Mailing Address - Phone:859-273-3774
Mailing Address - Fax:
Practice Address - Street 1:845 ANGLIANA AVE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40508-3146
Practice Address - Country:US
Practice Address - Phone:859-323-9321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-03
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1264101YA0400X
KY3003542207RA0401X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine