Provider Demographics
NPI:1760830269
Name:KELLEY, NICHOLAS (DO)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:KELLEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 N RIVER ST
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-2634
Mailing Address - Country:US
Mailing Address - Phone:570-829-8111
Mailing Address - Fax:
Practice Address - Street 1:575 N RIVER ST
Practice Address - Street 2:
Practice Address - City:WILKES-BARRE
Practice Address - State:PA
Practice Address - Zip Code:19702-2634
Practice Address - Country:US
Practice Address - Phone:570-829-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-25
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT017061390200000X
PAOS019482207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program