Provider Demographics
NPI:1902813652
Name:KELLY, MARY ELIZABETH (CNM)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:KELLY
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1213 1/2 QUINCY ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701
Mailing Address - Country:US
Mailing Address - Phone:605-415-8283
Mailing Address - Fax:
Practice Address - Street 1:1000 HEALTH CENTER ROAD
Practice Address - Street 2:
Practice Address - City:KYLE
Practice Address - State:SD
Practice Address - Zip Code:57752
Practice Address - Country:US
Practice Address - Phone:605-455-8219
Practice Address - Fax:605-455-1481
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCM000024176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife