Provider Demographics
NPI:1972133494
Name:PARKER, JOHN KELLY
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:KELLY
Last Name:PARKER
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 1:447 W LONGLEAF DR APT 901
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:AL
Mailing Address - Zip Code:36832-7414
Mailing Address - Country:US
Mailing Address - Phone:256-690-2124
Mailing Address - Fax:
Practice Address - Street 1:447 W LONGLEAF DR APT 901
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:AL
Practice Address - Zip Code:36832-7414
Practice Address - Country:US
Practice Address - Phone:256-690-2124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-23
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS12774390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program