Provider Demographics
NPI:1710649728
Name:KELLY, SHADOMBRIA
Entity Type:Individual
Prefix:
First Name:SHADOMBRIA
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 1:3320 WILCOX AVE
Mailing Address - Street 2:
Mailing Address - City:BELLWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60104-2169
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1346 E 53RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-4046
Practice Address - Country:US
Practice Address - Phone:773-947-0438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.304309183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist