Provider Demographics
NPI:1972259174
Name:KELLEY, BRETT LEE
Entity Type:Individual
Prefix:MR
First Name:BRETT
Middle Name:LEE
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:PO BOX 772
Mailing Address - Street 2:
Mailing Address - City:MOULTON
Mailing Address - State:AL
Mailing Address - Zip Code:35650-0772
Mailing Address - Country:US
Mailing Address - Phone:256-341-7676
Mailing Address - Fax:855-326-1353
Practice Address - Street 1:13414 AL HIGHWAY 157 STE B
Practice Address - Street 2:
Practice Address - City:MOULTON
Practice Address - State:AL
Practice Address - Zip Code:35650-3704
Practice Address - Country:US
Practice Address - Phone:256-341-7676
Practice Address - Fax:855-326-1353
Is Sole Proprietor?:No
Enumeration Date:2022-02-25
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL0500943146L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic