Provider Demographics
NPI:1023712163
Name:KELLEY, ETHEL MAE
Entity type:Individual
Prefix:
First Name:ETHEL
Middle Name:MAE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 S DAVIS RD STE 900
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30241-2609
Mailing Address - Country:US
Mailing Address - Phone:706-756-1489
Mailing Address - Fax:
Practice Address - Street 1:229 S DAVIS RD STE 900
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30241-2609
Practice Address - Country:US
Practice Address - Phone:706-756-1489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-30
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN3191402163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)