Provider Demographics
NPI:1891947743
Name:KELLEY, MARY CATHERINE (DOM)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:CATHERINE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28232 WILDLIFE LN
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34602-7456
Mailing Address - Country:US
Mailing Address - Phone:352-442-0216
Mailing Address - Fax:
Practice Address - Street 1:28236 WILDLIFE LN
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34602-7456
Practice Address - Country:US
Practice Address - Phone:352-442-0216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-22
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP1900171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist