Provider Demographics
NPI:1720564115
Name:KELLEY, TERESA D
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:D
Last Name:KELLEY
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 1:1735 27TH ST STE B06
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-2681
Mailing Address - Country:US
Mailing Address - Phone:740-356-8681
Mailing Address - Fax:740-356-1256
Practice Address - Street 1:1805 27TH ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-2686
Practice Address - Country:US
Practice Address - Phone:740-356-8231
Practice Address - Fax:740-356-3686
Is Sole Proprietor?:No
Enumeration Date:2018-07-18
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3012519367500000X
OHAPRN.CRNA.0020697367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered