Provider Demographics
NPI:1780208918
Name:KELLY, MELISSA MARIE (RN)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:MARIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12969 E GONZALEZ ST
Mailing Address - Street 2:
Mailing Address - City:DEWEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86327-8299
Mailing Address - Country:US
Mailing Address - Phone:602-717-1165
Mailing Address - Fax:
Practice Address - Street 1:500 N US HIGHWAY 89
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86313-5001
Practice Address - Country:US
Practice Address - Phone:928-445-4860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-03
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN171106163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse