Provider Demographics
NPI:1861023343
Name:KELLY, STEPHEN M
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:M
Last Name:KELLY
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:N8021 LAKE BREEZE DR
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:WI
Mailing Address - Zip Code:54169-9613
Mailing Address - Country:US
Mailing Address - Phone:920-989-7934
Mailing Address - Fax:
Practice Address - Street 1:N8021 LAKE BREEZE DR
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:WI
Practice Address - Zip Code:54169-9613
Practice Address - Country:US
Practice Address - Phone:920-989-7934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-03
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer