Provider Demographics
NPI:1710020474
Name:KELLIE, LAURA GAIL (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:GAIL
Last Name:KELLIE
Suffix:
Gender:F
Credentials:MD
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 950293
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0293
Mailing Address - Country:US
Mailing Address - Phone:405-682-3303
Mailing Address - Fax:405-792-8993
Practice Address - Street 1:6400 DUTCHMANS PKWY
Practice Address - Street 2:SUITE 15
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-3340
Practice Address - Country:US
Practice Address - Phone:502-895-0524
Practice Address - Fax:502-897-5798
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY40675208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics