Provider Demographics
NPI:1790443513
Name:KELLEY, DAMON J
Entity Type:Individual
Prefix:
First Name:DAMON
Middle Name:J
Last Name:KELLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1198 PEA RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:PHILIPPI
Mailing Address - State:WV
Mailing Address - Zip Code:26416-7585
Mailing Address - Country:US
Mailing Address - Phone:304-457-1558
Mailing Address - Fax:
Practice Address - Street 1:1408 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:ELKINS
Practice Address - State:WV
Practice Address - Zip Code:26241-3325
Practice Address - Country:US
Practice Address - Phone:304-636-4390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-30
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant